Physicians Say Prior Authorization Leads to Bad Outcomes

More than 90% of physicians said in a new survey that health plans’ prior authorization requirements lead to delayed care and bad outcomes. In the survey from the American Medical Association, physicians said prior authorization policies have a negative effect on patient outcomes and lead to physician burnout and lowered employee productivity.

Bruce A. Scott, M.D.

“Payers erect roadblocks and hurdles allegedly designed to save money for the health system and protect precious resources, but when patients and their doctors face care delays — or even give up and abandon necessary care — the result can actually be increased overall costs when worsening health conditions force patients to seek urgent or emergency treatment,” AMA President Bruce A. Scott, M.D. in a statement that accompanied the survey.

The AMA surveyed 1,000 practicing physicians in a web-based survey in December 2023. Of these, 40% were primary care physicians and 60% were specialists.

The survey found that 24% of patients reported that prior authorization has led to serious adverse events, including hospitalization, permanent impairment or death. Additionally, 78% said patients abandoned treatment because of prior authorization.

Physicians also reported higher administrative burden and wasted resources for their practices. Physicians reported completing an average of 43 prior authorizations per week, and 27% of physicians reported that prior authorization requests are often or always denied.

Prior authorization requirements for a single physician consume the equivalent of 12 hours of physician and staff time each week, and 35% of physicians employ staff members to work exclusively on tasks associated with prior authorization.

Physicians reported that resources were diverted to ineffective initial treatments (69%), additional office visits (68%), urgent or emergency care (42%), and hospitalizations (29%) because of prior authorization requirements.

The requirement to speak with a physician peer at health plans is increasing and disruptive, impacting physicians’ ability to see patients. The survey also found 15% of physicians said that the peer at the health plan was not qualified to make a determination.

“I know firsthand that the lack of transparency in the denial process is one of the most frustrating aspects of modern medicine,” Scott said.

He pointed to a recent patient with a tumor growing in the sinus next to her eye whose insurance company denied authorization for the surgery because she had not tried an antibiotic and a nasal spray, which would not cure the tumor. “After a phone call to the medical director, the surgery was approved, but imagine the stress for her, when she received a letter from her insurer saying that the surgery was ‘not medically necessary.’ That’s just wrong, and our patients deserve better,” he said.

Marilyn Heine, M.D.

The AMA supports reform of prior authorization. The AMA wants to see greater transparency of prior authorization denials and great accountability to insurers when prior authorization harms patients. The physician organization adopted reform policies during its annual meeting earlier this month. “To protect patient-centered care, the AMA will work to support legal consequences for insurers that harm patients by imposing obstacles and burdens that interfere with medically necessary care,” AMA Board Member Marilyn Heine, M.D., said in a news release.

The AMA wants to see detailed explanations regarding the rationale for denying access to care, including detailed explanation of denial reasoning, access to policies or rules cited as part of the denial, information needed to approve the treatment, and a list of covered alternative treatments.

The Centers for Medicare & Medicaid Services (CMS) issued a final rule in January 2024 that requires health plans to offer electronic prior authorization technology that directly integrates with electronic health records. This could reduce the burden for physicians and result in an estimated $15 billion in practice savings over 10 years, according to the U.S. Department of Health and Human Services.

As part of this new rule, beginning in 2026, Medicare plans will be required to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests for medical items and services. The rule also requires payers to include a specific reason for denying a prior authorization request, which the HHS said will help facilitate resubmission of the request or an appeal when needed.