Building on years of advocacy on every front to streamline burdensome prior authorization requirements, physicians, residents and medical students at the Special Meeting of the AMA House of Delegates (HOD) today adopted new policies specifically targeting peer-to-peer (P2P) review of prior authorization decisions and the particular burden of prior authorization during a public health emergency.
Specifically, P2P conversations refer to discussions between a physician and an insurance company physician employee that frequently take place, depending on the health plan, either during the initial prior authorization process or after an initial prior authorization denial. These conversations typically involve questions of medical necessity or treatment requests.
The new policies adopted call for:
- P2P prior authorizations to be made actionable within 24 hours of the discussion;
- The reviewing P2P physician to have clinical expertise to treat the medical condition or disease under review and to have knowledge of the current, evidence-based clinical guidelines and novel treatments;
- P2P reviewers to follow evidence-based guidelines consistent with national medical society guidelines where available and applicable;
- Temporary suspension of all prior authorization requirements and the extension of existing approvals during a declared public health emergency;
- And health plans must not require prior authorization on any medically necessary surgical or other invasive procedure related or incidental to the original procedure if it is finished during the course of an operation or procedure that was already approved or didn't require prior authorization.
"Delayed and disruptive treatment due to unnecessary and bureaucratic prior authorization requirements can have life-or-death consequences for patients - something we know from data and surveys of physicians," said AMA President Susan R. Bailey, M.D. "P2P reviews are another burdensome layer insurers are increasingly using without justification, and the peer reviewers are often unqualified to assess the need for services for a patient for whom they have minimal information and to whom they have never spoken or evaluated. Particularly during a public health emergency like COVID-19, unnecessary prior authorizations should not stand between a patient and care they need."
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals and health plans signed a consensus statement outlining a shared commitment to improving five key areas associated with the prior authorization process. However, health plans have made little progress in the last three years toward implementing improvements in each of the five areas outlined in the consensus statement.
Through our research, collaborations, advocacy and leadership, the AMA is working to right-size prior authorization programs so that physicians can focus on patients rather than paperwork. Patients can share their own personal experiences with prior authorization at FixPriorAuth.org.