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Prior Authorization Negatively Impacts Clinical Outcomes

Payers of medical costs have used prior authorization (PA) for years to prevent unnecessary care and possible fraud. A survey conducted by the American Medical Association in 2018 revealed that over 90% of physicians found the practice unduly burdensome because of its negative impact on clinical outcome. 64% of physicians will wait at least one business day for prior authorization decisions and 30% will wait three business days or longer. 34% of physicians in a 2021 subsequent survey reported a PA led to a serious adverse event for a patient under their care.

Some payers require authorization for simple care such as generic medications. 30% of physicians claim PA programs are not based on evidence-based guidelines. A simple phone call can mushroom into a protracted back and forth that only delays a patient’s access to vital medical care. Physicians and their staff spend 13 hours per week on average completing PAs. Nearly 80% of physicians reported that patients will abandon a recommended course of care due to the preauthorization maze. In this age of health coverage contraction, patients have limited choices if they want to change health plans. Some suggestions for overhauling the authorization process include speeding up the adoption of electronic standards for prior authorization that will eliminate denials for non-clinical reasons, and employing professionals beyond physician offices who understand the language of medicine. Professional organizations have spoken out that “reducing administrative burden is a must” to not only reduce provider stress but, most importantly, improve patient outcomes.