AMA pressures federal government to fix prior authorization problem plaguing radiology
The American Medical Association is increasing its pressure on the federal government to fix a prior authorization process that has plagued radiology and other medical specialties.
AMA on Monday released new survey data, which found that 89% of providers polled believe that this tactic used by health insurers has had a negative impact on care. Just last month, AMA and nearly 120 physician groups (including two in radiology) urged the Centers for Medicare & Medicaid Services to address this utilization-management tactic they believe is hindering the healthcare system.
“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care, and harm patients,” dermatologist and AMA President Jack Resneck Jr., MD, said in a March 13 statement announcing the survey results. “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.”
Monday also was the deadline to submit comments to CMS on a proposed rule to speed up the prior authorization across Medicaid, Medicare Advantage and Affordable Care Act marketplace plans. Beginning in 2026, the rule would force payers to respond to prior authorization requests within a week (rather than 14 days) and 72 hours if the healthcare service is urgent, Kaiser Health News reported March 13. AMA highlighted its own 62-page comment letter on the rule, submitted Monday.
A total of 1,000 practicing physicians responded to the recent survey, including 600 specialists. About 94% said that prior authorization results in care delays, including 14% who said “always,” 42% who said “often” and 37% who said “sometimes.” Another 80% of medical doctors surveyed said that prior authorization can at least sometimes lead to patients abandoning their recommended course of treatment.
The Kaiser report highlighted instances where prior authorization policies directly impacted individuals seeking imaging. Paula Chestnut, for example, received an X-ray prior to hip surgery, which unearthed irregularities in her chest. A specialist in Los Angeles recommended an MRI to assess further, but her health insurer labeled the scan as medically unnecessary and refused to cover it. She later died in the hospital after a large tumor was discovered in her chest.
Amid pressure from patients and providers, some payers are responding. UnitedHealthcare, for one, has halved its number of prior authorizations in recent years, including cutting back the need to obtain permission for certain MRIs, CT scans and other diagnostic procedures, the KHN report noted. Radiologists face the heaviest burden from prior authorization, behind only radiation oncology and cardiology, a recent JAMA Health Forum analysis found.
“The people who are making these decisions are rarely in your field of medicine,” Julie Kanter, MD, a hematologist in Birmingham, Ala., told Kaiser Health news. “It’s a terrible system.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.