Dive Brief:

• Physicians say prior authorization continues to pose barriers to offering timely and medically necessary treatment, according to a new survey from the American Medical Association.
• Nearly all of the physicians surveyed in December said prior authorization resulted in care delays at least some of the time and had a negative impact on patient clinical outcomes.
• Most respondents said prior authorization denials had increased over the last five years, with nearly a third of respondents reporting their requests are often or always denied. Physicians reported concerns denial rates could grow further as insurers adopt artificial intelligence tools to review claims.

Dive Insight:

Physicians have long criticized prior authorization requirements, saying the process puts additional administrative requirements on providers and requires patients to jump through hoops to get necessary medical care.

Almost one in three physicians surveyed by the AMA said prior authorization criteria are rarely or never evidence-based. The majority of respondents said prior authorization led to overall higher medical utilization, with 77% of physicians reporting patients had to first attempt an ineffective initial treatment.

At times, prior authorization can lead to care delays that significantly impact a patient’s health, respondents said. More than a fourth of physicians said prior authorization led to a serious adverse event for a patient in their care. Twenty-three percent reported a patient was hospitalized due to prior authorization, while 18% said prior authorization contributed to a life-threatening event and 8% said patients suffered a disability.

Physicians are concerned that prior authorization denials could accelerate in the coming years if more insurers turn to AI to review claims. 

While major insurers, including Blue Shield of California, claim that using AI to review prior authorization documents will reduce burden on physicians by providing near instantaneous decisions, the AMA is skeptical the tools will benefit providers.

In a press release accompanying the survey, the AMA cited a Senate report from October that found AI denied claims up to 16 times more than when a human reviewed them.

“Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care,” said Bruce Scott, AMA president, in a press release. “Medical decisions must be made by physicians and their patients without interference from unregulated and unsupervised AI technology.”

Lawmakers have expressed interest in overseeing insurers’ use of the tech and several insurers have been sued over their use of algorithms to review claims. Still, it is unlikely that insurers will back down from using the technology, experts previously told Healthcare Dive. Instead, it’s more likely that providers will need to adopt their own AI to submit claims.