Legislative Action Needed when Insurers won’t Pay for Preauthorized Care

Continued physician frustration with excessive and disruptive prior authorization controls required by health insurers resulted in calls for legislative and injunctive action by the American Medical Association (AMA) to fight retrospective denial of payment for care that has been pre-certified by an insurer.

Prior authorization signifies that the health plan has reviewed the medical necessity of the treatment and deemed it appropriate for coverage. Physicians and medical students at the AMA Interim Meeting of House of Delegates voted to adopt policy that deemed the insurer vetting process as more than adequate for payment after the services are performed.

“Prior authorization should be sufficient to guarantee payment,” said AMA Board Member Marilyn J. Heine, M.D. “It is unacceptable that a health plan gives a green light to medically necessary care and then retains or creates barriers to payment. It’s an affront to physicians, patients and employers; and leads to financial strain for practices and families.”

To protect patient-centered care, the new policy directs AMA to support a federal ban on inappropriate denial of payment from medical necessary care that has been pre-certified by an insurer. The AMA will also encourage legal action against insurers that engage in inappropriate post-service payment denials and payment recoupment.

Today’s actions by the 700-member House of Delegates adds to existing AMA policies and efforts aimed at fighting inappropriately imposed prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients.

The byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.

The AMA’s FixPriorAuth.org grassroots campaign and sustained advocacy have led to federal and state policymakers working toward prior authorization reforms in 2024 that include:

• The Centers for Medicare & Medicaid Services released final regulations making important reforms to prior authorization to cut patient care delays and electronically streamline the process for physicians.
• Lawmakers introduced this past June an updated, bipartisan version of the Improving Seniors’ Timely Access to Care Act in both the House (H.R. 8702) and Senate (S. 4532).
• Over a dozen states enacted laws this year supported by the AMA and state medical associations that reduce care delays and wasted time experienced by patients and physicians due to prior authorization requirements.

The AMA continues to work on every front to right-size prior authorization programs so that physicians can focus on patients rather than administrative burdens.

About the American Medical Association
The American Medical Association is the physicians’ powerful ally in patient care. As the only medical association that convenes 190+ state and specialty medical societies and other critical stakeholders, the AMA represents physicians with a unified voice to all key players in health care. The AMA leverages its strength by removing the obstacles that interfere with patient care, leading the charge to prevent chronic disease and confront public health crises and, driving the future of medicine to tackle the biggest challenges in health care.