New AMA policies attempt to revamp prior authorization process
The AMA said it has adopted new policies regarding the prior authorization process, with its outgoing president stating that maintaining the status quo may cause “life-or-death consequences.”
The AMA’s new policies involve the authorizations made during a public health emergency, and peer-to-peer (P2P) conversations between a physician and an insurance company physician employee either during the initial prior authorization process or after a prior authorization has been rejected, according to a press release.
The new policies call for:
- P2P prior authorizations to be made actionable within 24 hours of the conversation;
- reviewing P2P physicians to be clinically proficient in the medical condition or disease under consideration and to possess “knowledge of the current, evidence-based clinical guidelines and novel treatments”;
- P2P reviewers to adhere to evidence-based guidelines “consistent with national medical society guidelines where available and applicable”;
- temporarily suspending all prior authorization requirements and extending existing approvals during a declared public health emergency; and
- health plans to no longer require prior authorizations on “any medically necessary surgical or other invasive procedure related or incidental to the original procedure” if it is completed during an operation or procedure that was already approved or did not need a prior authorization.
An AMA survey conducted this past December showed that 94% of physicians experienced care delays while waiting for a health insurance company to authorize necessary care, 79% reported that patients have called off treatment due to authorization issues with health insurers and 30% said that prior authorization requirements have led to patients experiencing “a serious adverse event.”
Susan R. Bailey, MD, outgoing president of the AMA, pointed to that data as evidence the policies are needed.
“P2P reviews are another burdensome layer insurers are increasingly using without justification, and the peer reviewers are often unqualified to assess the need for services for a patient for whom they have minimal information and to whom they have never spoken or evaluated,” she said in the press release. “Particularly during a public health emergency like COVID-19, unnecessary prior authorizations should not stand between a patient and care they need.”
The policies were adopted during the AMA’s House of Delegates meeting, which is being held virtually this week.
AMA. AMA adopts new policies to rein in burdensome prior authorization policies that delay care. Available at: https://www.ama-assn.org/press-center/press-releases/ama-adopts-new-policies-rein-prior-authorization-burdens. Received June 15, 2021.
AMA. Most physicians had little relief from prior authorization as COVID cases soared. Available at: https://www.ama-assn.org/press-center/press-releases/most-physicians-had-little-relief-prior-authorization-covid-cases. Accessed June 16, 2021.