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AMA: Insurers not sticking to prior authorizations deal from 2018

Modern Healthcare


Health insurance companies haven't adequately implemented changes to the prior authorization process that insurers and providers devised in 2018, according to survey results the American Medical Association published Tuesday.


Four years ago, the AMA, AHIP, the Blue Cross Blue Shield Association and other healthcare groups agreed to encourage reviews of medical services and drugs subject to prior authorization, better communication about prior authorization processes, exemptions for some physicians and services, policies to promote continuity of care, and the adoption of electronic prior authorization systems.


But the AMA now says insurers haven't upheld their end of the bargain.


The AMA surveyed more than 1,000 doctors and found just 9% of respondents were contracted with health plans that exempt certain physicians from prior authorization requirements, although 29% of respondents said they didn't know if that option were available.


"Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action," AMA President Dr. Gerald Harmon said in a news release.


More than 60% of doctors said it's at least somewhat difficult to determine whether a medication or service requires prior authorization. According to the AMA, this indicates that insurers have ignored their agreement to encourage transparency and communication.


Additionally, physicians reported phone calls as the most common method for completing prior authorizations. Fax was the second-most common method, with 45% of respondents always or often using fax machines. Just 31% of physicians often use electronic health record systems for authorizations of, although 50% use EHRs for prior authorizations of prescriptions.


The number of prior authorizations has increased over the past five years, 84% of physicians reported. And 88% said prior authorization at least sometimes interferes with care continuity.

Blue Cross and Blue Shield companies are implementing prior authorization improvements, a Blue Cross Shield Association spokesperson wrote in an email.


"We are committed to working with providers around shared responsibilities for improving the process, promoting quality and affordable healthcare, reducing unnecessary burdens and ensuring timely access to clinically appropriate care," the spokesperson wrote.

AHIP did not respond to a request to comment on the AMA survey.


Providers and insurers have sparred over prior authorization for years. Insurers maintain that the tool contains costs and prevents unnecessary care.


About 85% of commercial health plan members are enrolled in plans that limit prior authorization to less than 10% of medications, and more than 90% are in plans that require authorization for fewer than 25% of medical services, according to a 2020 AHIP survey of health plans.


Roughly nine in 10 insurers reported efforts to streamline prior authorization, and most favored implementing automated systems. But 58% identified providers not using EHRs that support electronic prior authorizations as the biggest obstacle to that goal.


In conjunction with the survey, the AMA urged Congress to pass legislation to modify prior authorizations under Medicare Advantage. A House bill to revise that policy has 290 cosponsors.


The Health and Human Services Department's Office of Inspector General published a report last month charging that some Medicare Advantage carriers use prior authorization requirements as a means to deny medically necessary care. The American Hospital Association asked the Justice Department to investigate this practice under the False Claims Act last week.