AMA Sends Message to Insurers

Insurer prior-authorization rules have become one of the largest pain points for both physicians and their patients.

This recurring issue was tackled at the recently concluded American Medical Association’s (AMA) House of Delegates annual meeting in Chicago.

What’s required, said the AMA, is greater insurer accountability and transparency, specifically, “greater oversight of health insurers’ use of prior authorization controls on patient access to care.”

The AMA’s House of Delegates is its legislative and policy-making body that includes physicians, residents, and medical students from every state and medical specialty. Delegates work together to form a national physician consensus on current issues.

The AMA will promote greater legal accountability of health insurers in situations where prior authorization hurts patients. This policy is in response to the prior authorization policies of health plans that “conflict with evidence-based clinical practices, jeopardize quality care, and harm patients.”

The AMA relied on the knowledge and experience of its policy-making body as well as that of outside sources when developing its policies. Notably it cited physician surveys as well as investigations by the inspector general’s office of the Health and Human Services Department and Kaiser Family Foundation. The surveys found that unnecessary authorization controls have led to “serious harm.” The investigations “strongly suggest that insurers are denying medically necessary health care.”

AMA Board Member Marilyn Heine, M.D. commented, “Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health.”

Dr. Heine continued, “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.”

The AMA will also remain focused on the information provided by health insurers in prior authorization notifications. Notably, the AMA is prioritizing the need for detailed explanations when access to care is denied.

AMA policy details the information that should be included in the prior authorization denial letters. This includes, per the AMA press release, “a 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.” This policy is in response to denial processes by health insurers that are “notoriously opaque, complex, and inconsistent.”

Dr. Heine commented, “Health insurer denials must not be a mystery to patients and physicians.”

Dr. Heine continued, “Without clear information from an insurer on how a denial was determined, patients and physicians are often left to the frustrating guess work of finding a treatment covered by a health plan, resulting in delayed and disrupted care. Transparency in coverage policies needs to be a core value, an essential principle to help patients and physicians make informed choices in a more efficient health care system.”