The time-wasting, care-delaying, insurance company cost-control process known as prior authorization has gone from a rarely employed tool to discourage use of extremely pricey interventions to a form of utilization management that can be required for even the simplest generic medication.
Insurance companies’ overuse of prior authorization is causing patients real harm – in some instances even resulting in death. Nearly one-quarter of the 1,000 physicians the AMA surveyed (PDF) in late 2023 reported that prior authorization has led to a serious adverse event for a patient in their care, including 7% that said prior auth led to a patient’s disability or permanent bodily damage, congenital anomaly or birth defect or death.
Prior authorization is costly, inefficient and responsible for patient care delays. The AMA stands up to insurance companies to eliminate care delays, patient harm and practice hassles.
Prior authorization is overused, and existing processes present significant administrative and clinical concerns.
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Last month, a bipartisan congressional group introduced an updated version of the Improving Seniors’ Timely Access to Care Act in the House and Senate (H.R. 8702; S. 4532). Learn more about how the bill would boost older adults’ access to care by fixing prior authorization.
An AMA model bill (PDF) can help physicians get started on advocating change in their own state legislatures. Explore this collection of in-depth articles to learn more about the reforms that are needed, how the AMA is pushing for change, and what progress is being made.
It is likely that nearly every physician in the nation can share a horror story of having a medication they prescribed or procedure they ordered put through the prior authorization process, and then having to plead their case to move forward—only to wind up talking with someone who does not have the knowledge to make the clinical decision being discussed. It may be that the health professional on the other end is not a physician. Even when they are physicians, these insurer-paid “peers” often come from a completely different specialty or know little to nothing about the disease or treatment in question. For example, an insurer-employed ob-gyn may be asked to approve or deny a prior authorization dealing with neurosurgery. Physicians need to be able to quickly connect with a physician who practices in the same specialty as they do. Getting to someone who understands the patient’s condition and medically appropriate treatments can truly be a matter of life and death.
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Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
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