AMA calls for regulatory and injunctive actions for unpaid preauthorized care

Author(s):

Austin Littrell

Key Takeaways

The AMA is pushing for stronger regulations against insurers denying payments for pre-authorized services, aiming to protect patients and physicians from disruptions.
A new policy, supported by 700 physicians and medical students, advocates for federal prohibition and legal action against inappropriate post-service payment denials.
The AMA's "Fix Prior Auth" campaign has led to reforms by CMS and legislative efforts to streamline prior authorization processes and reduce patient care delays.
The AMA continues to advocate for a balanced approach to prior authorization, focusing on reducing administrative burdens and allowing physicians to prioritize patient care.

New policy would ensure AMA support for a federal prohibition on the inappropriate denial of payment for care that is necessary and has received prior authorization.

The American Medical Association (AMA) has called for stronger regulatory and legal measures against health insurers that deny payment for medical services they previously authorized as necessary. Announced during the annual AMA Interim Meeting of House of Delegates in Orlando, Florida, the policy is intended to protect patients and physicians from any disruptions that may be caused by retroactive payment denials, where insurers refuse to cover prior authorized services.

During the meeting, 700 physicians and medical students voted in favor of policy that would ensure AMA support of a federal prohibition on the inappropriate denial of payment for medical care that is both medically necessary and pre-certified. The policy also ensures the AMA would support legal action against insurers that engage in these inappropriate post-service denials of payment and payment recoupment. The policy comes in response to continued physician frustration with prior authorization requirements viewed as excessive and disruptive by health insurers.

“Prior authorization, once granted, should be sufficient to guarantee payment,” Marilyn J. Heine, MD, AMA board member, said in an organizational release. “It is unacceptable that a health plan gives a ‘green light’ to medically necessary care and then retains or creates barriers to payment. It’s an affront to physicians, patients and employers; and leads to financial strain for practices and families.”

Throughout their ongoing fight for patient and physician advocacy, the AMA has used their “Fix Prior Auth” campaign to champion several policies and influence policymakers. The Centers for Medicare & Medicaid Services (CMS) released final regulations, making important reforms to the prior authorization process that cut patient care delays and work to streamline the process for physicians. At the same time, the AMA-backed and bipartisan Improving Seniors’ Timely Access to Care Act has been introduced in both the House and Senate. Additionally, more than a dozen states have passed laws in 2024 aimed at reducing delays and wasted time from prior authorization procedures.

The AMA has expressed their intention to continue the correction of prior authorization programs, calling for a “right-sized” approach which would allow physicians to focus on patients, rather than administrative burdens.