AMA Joins with Other Organizations to Reform Prior-Authorization Requirements

The American Medical Association (AMA) and a coalition of 16 other organizations representing physicians, medical groups, hospitals, pharmacists and patients have devised a set of 21 principles to guide reform of utilization management (UM) programs, including prior-authorization and step-therapy requirements. The 21 principles are divided into five broad categories:

1. clinical validity, which includes UM criteria being based on up-to-date clinical criteria rather than cost alone, as well as flexibility to meet patient-specific needs;
2. continuity of care, designed to ensure that patients’ care isn’t disrupted by prior-authorization requirements;
3. transparency and fairness, addressing the need for detailed explanations for denials and full public disclosure of all coverage restrictions in a searchable, electronic format;
4. timely access and administrative efficiency, which establishes maximum response time for UM decisions and seeks health plans’ acceptance of electronic prior authorizations; and
5. alternatives and exemptions, which calls for health plans to offer at least one alternative to prior authorization.

In 2016, the AMA House of Delegates adopted in-depth policy on standardization and simplification of prior authorization. Several states have already passed legislation to protect patients from overly burdensome UM requirements. “Strict or bureaucratic oversight programs for drug or medical treatments have delayed access to necessary care, wasted limited healthcare resources and antagonized patients and physicians alike,” said AMA President Andrew W. Gurman, MD. “The AMA joins with other coalition organizations in urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs.”