AMA: Payers not following prior authorization reforms they agreed to in 2018

A new survey of physicians finds they are still facing burdens meeting prior authorization requirements despite a voluntary 2018 agreement among payer groups to reform the practice.

The survey was released Tuesday (PDF) by the American Medical Association (AMA) and comes amid criticism over prior authorization denials and requests in the Medicare Advantage space. The AMA spoke with more than 1,000 practicing physicians in December 2021 on the impact of prior authorization.

“Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death,” AMA President Gerald Harmon, M.D., said in a statement. “Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”

The 2018 agreement between the AMA and several insurer industry groups laid out five reforms on the prior authorization process intended to reduce administrative burden and ensure timely approvals and responses.

However, physicians surveyed by the AMA say some of the promised reforms have yet to fully take hold.

For instance, a part of the agreement is to encourage the use of programs that only selectively implement prior authorization based on the provider’s performance. However, only 9% of physicians surveyed reported “contracting with health plans that offer programs that exempt providers from [prior authorization].”

The survey also found that 65% and 62% of providers reported it is difficult to determine whether a prescription or a service requires a prior authorization request. A key tenet of the 2018 agreement was to encourage transparency of prior authorization requirements as well as the changes to contracted providers and patients.

Another key area of reform was to encourage providers and plans to accelerate the use of a national standard for electronic prior authorization to speed up the process for requests and approvals.

AMA’s survey, though, showed there is still a way to go with the adoption of electronic measures. Only 26% of doctors reported their electronic health record system enables electronic prior authorization for prescriptions.

Another 88% of physicians say that prior authorization interferes with the continuity of care.

Insurer groups say plans are committed to improving the prior authorization process.

“We recognize that prior authorization can be burdensome for everyone involved in the process, which is why health insurers target its use,” said David Allen, spokesman for the insurance industry group AHIP.

He said that 83% of commercial plan enrollees are in plans where less than 10% of the drugs need prior authorization, and 93% of enrollees are part of plans that have less than 24% of services subject to prior authorization.

The Blue Cross Blue Shield Association, which represents 35 Blue Cross insurers, said that its companies have waived prior authorization on several services throughout the pandemic.

“[Blue Cross Blue Shield] companies are actively implementing improvements supportive of both members and providers,” the group said in a statement to Fierce Healthcare.

The survey comes a few weeks after the Department of Health and Human Services’ Office of Inspector General released a report that found Medicare Advantage plans at times delayed or denied beneficiaries access to services that met Medicare’s coverage requirements.

The report spurred several lawmakers to call for mandated electronic prior authorization. The Improving Seniors’ Timely Access to Care Act, which has widespread bipartisan support, would standardize how Medicare Advantage plans use prior authorization as well as create an electronic prior authorization process.