The American Medical Association (AMA) has adopted a policy urging health insurers to implement fair and thorough processes for AI-driven prior authorization. The AMA seeks increased oversight, clinical criteria-based reviews, involvement of healthcare professionals, and human examination of patient records. While supporting automation, the AMA highlights the inefficiency and burden of prior authorization. The policy is part of the AMA’s efforts to reform prior authorization and improve patient care. It comes as AI and automation are being used by payers, such as Florida Blue, to expedite prior authorization decisions.
The American Medical Association (AMA) has recently adopted a policy to address concerns regarding the use of artificial intelligence (AI) in the prior authorization process. The policy aims to establish a more comprehensive and equitable approach by health insurers utilizing AI, ensuring timely patient care.
During the AMA’s Annual Meeting, the House of Delegates approved the new policy, advocating for increased regulatory oversight of AI implementation by health insurers in the prior authorization process.
The AMA policy urges payers to adopt practices that involve thorough and fair reviews of patient claims and prior authorization requests. These processes should be based on clinical criteria and involve healthcare professionals with expertise in the specific service being reviewed. Importantly, these professionals should have no incentives to deny care.
Furthermore, the policy recommends that payers require a human examination of a patient’s records before making any decisions regarding care denial.
These recommendations come as the AMA strives to address the challenges posed by automation in prior authorization. The organization acknowledges the potential benefits of AI in reducing the burden on clinicians and expediting prior authorizations. However, it also highlights the inefficiency, high costs, overuse, and resulting delays in patient care associated with the current prior authorization system.
In a press release, AMA Board Member Marilyn Heine, MD, emphasizes that while AI can be a valuable tool, it is not a solution on its own. Health insurance companies increasingly rely on AI for cost-effective prior authorization reviews. However, the sheer volume of prior authorization requirements remains a significant burden for physicians and creates barriers to patient care. The primary goal is to reduce the number of procedures subject to prior authorization.
To support its advocacy, the AMA plans to conduct research on the costs associated with prior authorization, using data from various sources, including the AMA’s datasets.
This policy forms part of the AMA’s Recovery Plan for America’s Physicians, which seeks to address prior authorization reform, physician burnout, and scope creep while enhancing patient care.
Prior authorization has become a contentious issue for healthcare providers and payers in recent years. A recent AMA survey indicated that prior authorization imposes administrative burdens on clinicians and disrupts care continuity for patients.
AI and automation have been proposed as potential solutions to these challenges, and several payers have already implemented these strategies. For example, in February of last year, Florida Blue, a subsidiary of GuideWell, became the first US payer to automate prior authorization approvals. By partnering with health technology company Olive, they employed an AI-powered clinical review tool to shift decision-making to the point of care. This approach aimed to reduce administrative burdens for care teams and ensure timely and appropriate care. The full-scale implementation of this AI system for over 2.5 million members was scheduled to go live in July 2022.
