Physicians warn that AI will undermine judgement, increase prior authorization denials

doctor fills out medical prior authorization paperwork: © Pakin - stock.adobe.com

Many physicians are raising concerns over the increasing use of artificial intelligence (AI) in health insurers’ prior authorization processes, warning that automated denials are amplifying patient harm and physician burnout, according to the American Medical Association’s (AMA’s) latest “2024 AMA Prior Authorization Physician Survey.”

The AMA’s nationwide survey of 1,000 practicing physicians (400 primary care physicians, 600 specialists) found that 61% are concerned AI-driven prior authorization decisions are leading to more denials, and 75% reported that prior authorization denials have increased over the past five years.

The findings suggest that insurers’ growing reliance on unregulated AI decision-making tools could systematically deny patients access to necessary medical care.

AI denials and delayed care

Prior authorization has long been a source of frustration for physicians, adding hurdles to timely treatment. However, the introduction of AI has brought with it a new layer of concern, as many AI systems generate prior authorization decisions with minimal or no human review.

The AMA prior authorization survey found that:

• Patient harm: 29% reported that prior authorization has resulted in a serious adverse event, including hospitalization, permanent impairment or death.
• Poor outcomes: 94% said prior authorization negatively impacts patient clinical outcomes.
• Delayed care: 93% of physicians reported that prior authorization delays access to necessary care.
• Disrupted care: 82% of physicians stated that prior authorization leads to treatment abandonment.
• Shifted costs: 80% of physicians reported that prior authorization delays or denials require that patients pay out-of-pocket for medications “at least sometimes.”
• Lost workforce productivity: 58% of physicians who cared for patients in the workforce reported that prior authorizations have impeded a patient’s job performance.

“Using AI-enabled tools to automatically deny more and more needed care is not the reform of prior authorization physicians and patients are calling for,” Bruce A. Scott, MD, president, AMA, said in an organizational release. “Emerging evidence shows that insurers use automated decision-making systems to create systemic batch denials with little or no human review, placing barriers between patients and necessary medical care.

“Medical decisions must be made by physicians and their patients without interference from unregulated and unsupervised AI technology.”

Administrative burdens

The survey also highlighted the burden that prior authorization imposes on physicians and their practices. On average, physicians complete 39 prior authorizations per week, consuming 13 hours of physician and staff time. Nearly one in three physicians (31%) reported that prior authorization requests are “often” or “always” denied — leading to frequent appeals that further strain practice resources.

Forty percent of physicians employ staff members solely to manage prior authorization-related tasks, and 89% reported that prior authorization significantly contributes to physician burnout. Another two-thirds (65%) of responding physicians reported being required to participate in time-consuming “peer-to-peer” reviews with insurers.

Despite insurer claims of reducing prior authorization requirements, physicians report seeing little real-world impact.

Among those who work with UnitedHealthcare (UHC) and Cigna — the first and fourth largest U.S. health insurers by market share, respectively — only 16% noticed a decrease in prior authorization requests by the insurers.

In the survey, physicians ranked UHC as the insurer with the highest prior authorization burden, followed by Humana, Anthem/Elevance, Aetna, Cigna, and Blue Cross Blue Shield.

There was overwhelming support for regulatory oversight of insurers’ use of AI in prior authorization decisions, with 49% ranking it among their top three priorities for action. The AMA has called for AI to be used as an augmenting tool, rather than a replacement for human decision-making, ensuring that medical necessity determinations prioritize patient health over cost-cutting algorithms.

The AMA continues to advocate for prior authorization reform, encouraging physicians to share their personal experiences at FixPriorAuth.org.