“Our patients are suffering because insurers, even during a pandemic, are choosing profits over patient care—this must stop….because insurers will not change their ways despite their rhetoric, policymakers have an important opportunity to rein in prior-authorization requirements that adversely affect patient health.”
– Susan R. Bailey, MD, AMA President

Now, more than ever, is the time to support the American Medical Association (AMA) in their efforts with Congress, insurance payers, and government agencies to streamline the prior authorization process. In a push that started more than two years ago, the AMA advocates using electronic prior authorization technology, cutting down on the number of procedures, tests, and medications requiring approval and establishing two-day guidelines for insurance payers approvals.

Responding to the recent hearing called by the National Committee on Vital and Health Statistics (NCVHS), a federal advisory committee convened to put forth recommendations on electronic healthcare transaction standards to the US Department of Health and Human Services (HHS), the AMA testimony stated:

“The AMA maintains that health plans must reduce the overall volume of prior authorization requirements for the industry to achieve real progress on this issue; automation alone is not a full solution to the prior authorization problem….Even the most streamlined, widely deployed electronic prior authorization process cannot protect patients from clinical harm or physicians from administrative burdens if health plans do not apply utilization management requirements more judiciously and rationally.”

The AMA testimony further highlighted the results of the 2019 AMA Prior Authorizations Physicians Survey, including:

  • 91% of physicians report that prior authorizations cause delays in access to necessary care.
  • 24% of physicians state that prior authorizations have led to a serious adverse event for a patient in their care.
  • Physicians report completing an average of 33 prior authorizations per week.
  • Prior authorization workflow takes an average of two full business days for physicians and staff.

Another HHS advisory group, the Workgroup for Electronic Data Interchange (WEDI), put forth their data, mirroring the 2019 AMA Prior Authorization Physician Survey. In the WEDI report, a full 84% of providers stated that prior authorizations have increased over the last year.

In additional testimony, CAQH CORE board members also submitted their recommendations in a letter to NCVHS noting that the healthcare industry system-wide could save $12.31 per prior authorization by moving to an electronic process.

Where This Began

In a statement released in 2018, the AMA, along with many other healthcare-related professional groups and state associations, and participants from the insurance payer industry issued a call for reform that included the following:

  • Requiring prior authorizations based on standards like provider adherence to evidence-based medicine.
  • Annual review of requirements meant to eliminate prior authorizations for procedures, tests, and medications that have low utilization or low denial rates.
  • Improved transparency for the criteria and rationale when prior authorizations are required or are rejected.
  • Technological improvements to improve the efficiency of prior authorization processes.
  • Continuity of care for patients that change insurers during on-going care.

Contrary to the intentions, since 2018, insurance payers have only increased the number of procedures, tests, and medications requiring pre approval and have done very little in accommodating the concerns voiced in the letter.

What You Can Do to Support the AMA’s Efforts

Your voice lent to the discussion will impact and directly support the AMA’s continued efforts. Here some ways you can make a difference:

  • The AMA has an extensive prior authorization resources page that summarizes initiatives and opportunities.
  • Get involved with your state or local medical association where grassroots campaigns are active.
  • Contact your congressional representatives to approve HR 3107, the House bill that standardizes prior authorizations for Medicare.
  • Contact your state and local representatives as well.

Be Proactive — Improve Your Prior Authorization Process

Even when all is said and done, prior authorizations are here to stay. They provide an important check and balance on costs within the medical industry and will exist in some form once they are hopefully brought back to their initial purpose.

With 87% of prior authorizations being performed manually, consider the benefits your hospital or practice would recognize by automating the process.

To outline, AI-driven software can be integrated bi-directionally with the hospital or practice’s EHR/EMR and the billing system being used for client management through cloud-based technology. As soon as the patient’s order is input, tests or medications requiring prior authorizations would be electronically identified, provider/facility detail, patient demographics, and test/diagnosis information would be collected, and an approval request submitted in real-time to the insurance payer portal required.

Automation and AI-driven software with machine learning capabilities would access continually updated insurance information clearinghouses storing thousands of insurance groups and plans, each with their own unique guidelines and requirements, and electronically determine the prior authorization parameters for routing the request.

Prior authorization approvals that once took between hours to several days to initiate can now be accomplished in seconds with a 98+% accuracy rate.

Contact Infinx today to discuss their tech-enabled Prior Authorizations Software Solution.