Physicians say prior authorization leads to care complications, but health plans say process rooted in clinical evidence


Physicians say prior authorizations continue to interfere with patient care, causing treatment delays and adverse events, according to new survey data from the American Medical Association. While health plans agree the process is burdensome, they argue it adheres to clinical guidelines and is used in selective circumstances.

According to the AMA's survey, 16 percent of physicians said prior authorizations led to a patient hospitalization, while 24 percent said the process led to a serious adverse event for their patient. The survey results are based on answers from a sample of 1,000 practicing physicians gathered from a web-based survey in December 2019. 

The findings come more than two years after prominent provider and payer associations including the AMA, America's Health Insurance Plans, the American Hospital Association, the Blue Cross Blue Shield Association and others signed a consensus to improve the prior authorization process. AMA President Susan Bailey, MD, said June 23 that since the consensus was signed, "little progress has been made toward the reform goals."

That's not to say health insurers have been quiet on prior authorizations. In January, AHIP debuted a prior authorization pilot that aims to fast-track the process. The Fast Prior Authorization Technology Highway, or Fast PATH, aims to relieve administrative burden on providers by using automation software from technology companies Availity and Surescripts to digitize prior authorization processes. Health insurers covering more than 60 million Americans have agreed to participate in the pilot. These include Anthem, Blue Shield of California, Cambia's affiliated health plans, Cigna, Florida Blue and WellCare.

In addition, several health insurers are extending prior authorizations for elective services that have been canceled or deferred because of COVID-19, though most of those changes are temporary. 

In a statement to Becker's, David Allen, an AHIP spokesperson, said: "Prior authorization is an important tool that helps ensure that patients receive care that is safe, effective and necessary. However, we know that prior authorization can be improved. We're committed to reducing unnecessary burden, increasing patient satisfaction, and improving quality and outcomes." He cited a survey that found most health insurers develop prior authorization processes in concert with physicians, and that more than 90 percent of commercial enrollees are in plans that limit prior authorization to less than a quarter of medical services.

Still, physicians continue to find the process in need of change. Rep. Ami Bera, MD, D-Calif., said in a statement that "physicians spend far too much time on burdensome paperwork and seeking authorization on certain items, when they can be spending that time taking care of their patients." Dr. Bera has introduced legislation aimed at improving the process.

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