94% of physicians report care delays due to prior authorization, AMA says

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Ninety four percent of physicians report delays in care associated with prior authorization, according to a recent survey released by the American Medical Association.

The survey underscores the urgent need for reform and regulation of prior authorization, the AMA said. 

In December 2022, the Centers for Medicare and Medicaid Services released a proposed rule to speed up prior authorization approval. The deadline to submit comments was March 13.

WHY THIS MATTERS

Physicians spend almost two business days each week on prior authorization requests and 35% have had to hire additional staff to exclusively handle the administrative burden, the AMA said.

The AMA said other survey results show that 80% of physicians report that prior authorization can at least sometimes lead to treatment abandonment; 33% of physicians report prior authorization leading to a serious adverse event for a patient in their care – with 9% reporting it's led to permanent bodily damage, disability or death. 

Prior authorization complexity does not eliminate unnecessary treatments, the AMA said. Eighty-six percent of physicians report that prior authorization leads to higher overall utilization of healthcare resources. 

Many ophthalmologists have faced – and continue to face – broad prior authorization policies on cataract surgeries from certain insurance giants, the AMA said. 

Rheumatologists have long decried prior authorization policies for worsening outcomes for their patients. Many rheumatology patients rely on expensive biologic medication to treat their disease, meaning they are commonly a target of insurers, the AMA said. 

THE LARGER TREND

Through a rule proposed in December 2022, the Centers for Medicare and Medicaid Services wants to change prior authorization standards to speed up the time it takes for payers to approve the requests. CMS is proposing to require certain payers, including Medicare Advantage organizations, to implement electronic prior authorization and to send decisions within 72 hours for expedited requests and seven days for nonurgent requests.

Prior authorization is adding to physician and clinician burnout, according to Surgeon General Vice Admiral Vivek Murthy.

In a study released last year, the Office of the Inspector General recommended protocols for Medicare Advantage Organizations in denying prior authorization requests. 

States have passed gold card PA exemptions for certain physicians.

Congress is looking at bipartisan legislation to rein in prior authorization in Medicare Advantage. 
 

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org

Stephanie Chia, Russ Hinz and Susan Tolin will offer more detail in the HIMSS23 session "Equity on Chicago's South Side: Connected Care Technology." It is scheduled for Wednesday, April 19 at 1 p.m. - 2 p.m. CT at the South Building, Level 1, room S103.