In December 2018, the AMA conducted a web-based survey of physicians to ascertain the impact prior authorization (PA) is having on their ability to help their patients. PA is a health plan cost-control process that restricts access to treatments, drugs and services. This process requires physicians to obtain approval prior to the delivery of the prescribed treatment, test or medical service, in order to qualify for payment.
Originally, PA was designed for newer medications or procedures that were more expensive than the traditional methods. Now the practice has spread to routine items that are neither costly nor new.
Over 90% of the respondents indicated that PA had a significant or somewhat negative clinical impact. Nearly three in ten reported that PA led to a serious adverse event for a patient in their care such as a death, hospitalization, disability, permanent bodily damage, or other life-threatening event . The administrative burden of PA has become high or even extremely high. Also frustrating is that PA is regulated by state law in many states, while other states do not have a specific law.
The time frame for the reviewer to respond to urgent matters ranges from 24 to 72 hours to a “reasonable” period of time. In clinical reality, timely access to care can be a life or death matter.
1 in 4 doctors say prior authorization has led to a serious adverse event
Streamlining the Insurance Prior Authorization Debacle
Transforming Prior Authorization to Decision Support
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