Payer prior authorization continues to create roadblocks

Doctors surveyed by the American Medical Association said the payer prior authorization (PA) process creates delays in care, abandoned treatments, and impacts outcomes.

The complexity and inconsistencies of payer PA processes continue to create roadblocks to care for both patient and providers, including hospitals. Although the American Medical Association, along with the American Hospital Association, America’s Health Insurance Plans, the American Pharmacists Association, the Blue Cross Blue Shield Association and the Medical Group Management Association, released the “Consensus Statement on Improving the Prior Authorization Process1 (CS) in January 2018, as of December 2021, nearly four years later, an AMA survey of 1004 practicing physicians2 revealed that health plans have yet to widely implement these reforms.

The Prior Authorization cost-control process continues to interfere with care, sometimes even leading to adverse clinical consequences.2 Healthcare and hospital leaders need to proactively engage with professional associations, government, and payers to shape the process to avoid unintended harm to patient, as well as unnecessary use of resources – including time and money — that sometimes are a byproduct of PA systems.

Summary of key survey findings:

  • 93% of the participants reported their patients experienced treatment delays when services required PAs.
  • 82% reported that PAs can, at least sometimes, lead to treatment abandonment.
  • 30% reported that PA criteria are rarely or never evidence-based (although 98% of health plans reported they use peer-reviewed evidence-based studies when designing their PA programs)
  • 91% reported that PAs have a negative effect on clinical outcomes.
  • 34% reported that a PA had led to a serious adverse event for a patient in their care.

Those surveyed also stated that physicians and staff spend a total, on average, of 2 days of their week work on PAs. See the full survey here.


References

  1. “Consensus Statement on Improving the Prior Authorization Process.”
  2. 2021 AMA Prior Authorization Physician Survey.
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