Health insurers’ use of AI is bringing a new level of concern to the burdensome payer cost-control practice known as prior authorization. In a recently released AMA survey (PDF), 61% of physicians said they fear that payers’ use of unregulated AI is increasing prior authorization denials, a practice that will override good medical judgment and exacerbate patient harm.
“Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care,” said AMA President Bruce A. Scott, MD, reacting to the survey results.
Physicians should be able to make medical decisions with their patients without interference from unregulated and unsupervised AI technology, said Dr. Scott. The AMA is fighting by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Health plans use prior authorization to control costs, requiring advance approval to obtain a prescription medication or medical service for a patient. Physicians and patients alike view this as a burdensome practice that affects care delivery, clinical outcomes and productivity in physician offices. Spending rises under this practice due to additional office visits, unanticipated hospital stays, and out-of-pocket costs for treatment.
In this most recent nationwide survey of 1,000 practicing physicians—400 working in primary care, the remainder in other physician specialties—82% reported that prior authorization sometimes leads to patients abandoning treatment. Over 90% said prior authorization delays care.
AI tools have been accused of producing high rates of care denial, in some cases 16 times higher than is typical, according to figures from a 2024 Senate committee report cited in the AMA’s news release.
“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,” said Dr. Scott.
Other AMA surveys underscore physician concerns about some misuses of health care AI. Results released early in February (PDF) found that 49% of physicians ranked oversight of payers’ use of AI in medical necessity determinations among the top three priorities for regulatory action. To address these concerns, the AMA House of Delegates recently adopted policy supporting advocacy to help ensure that technology is an asset to physicians and not a burden. Based on this policy, the AMA has developed advocacy principles (PDF) that address the development, deployment and use of health care AI, with particular emphasis on:
- Health care AI oversight.
- When and what to disclose to advance AI transparency.
- Generative AI policies and governance.
- Physician liability for use of AI-enabled technologies.
- AI data privacy and cybersecurity.
- Payer use of AI and automated decision-making systems.
Dire consequences for patient care
AI concerns notwithstanding, physicians continue to report that prior authorization impedes delivery of necessary medical treatments, jeopardizes quality care and harms patients. More than nine in 10 physicians—94%—reported that prior authorization had a negative impact on clinical outcomes.
Eighty percent of doctors surveyed said that prior authorization sometimesleads patients to pay out-of-pocket for a medication, and 31% said payers are rarely or never using evidence-based criteria to make coverage decisions.
More distressingly, 29% of physicians reported that prior authorization led to a serious adverse event for a patient in their care.
More specifically, these shares of physicians said that prior authorization led to:
- A patient’s hospitalization—23%.
- A life-threatening event, or one that required intervention to prevent permanent damage—18%.
- A patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death—8%.
More burdens for physicians
Physicians also feel the administrative burden of prior authorization, which reduces their time with patients and negatively affects their practices. On average, physicians and their staff spend 13 hours a week completing the prior authorization workload for a single physician. Forty percent of physicians employ staff whose primary job is to work on this task.
These shares of physician respondents also revealed that prior authorization:
- Somewhat or significantly increases physician burnout—89%.
- Has increased somewhat or significantly over the last five years—75%.
- Is often or always denied—31%.
In cases of adverse payer decisions on prior authorization requests, 20% of physicians will always appeal. Physicians report various reasons for not appealing health-plan denials, with 67% reported doubts about an appeal’s success based on their past experiences. Over half said patient care could not wait for the health plan’s approval process, and 55% said they had insufficient resources to file an appeal.
The cost of prior authorization
The survey also revealed that prior authorization adds significant costs to the U.S. health system, forcing patients to try ineffective treatments and schedule additional office visits.
A strong majority of physicians—88%—reported that prior authorization leads to higher overall utilization of health care resources. These shares of physicians reported that prior authorization increases utilization in the following ways:
- Led to ineffective initial treatment—77%.
- Additional office visits—73%.
- Immediate care or emergency department visits—47%.
- Hospitalizations—33%.
Prior authorization can also affect productivity in the workplace, if employees are missing work due to delays in care leading to prolonged illness or attending rescheduled appointments. Nearly 60% of physicians with patients in the workforce said prior authorization has affected work performance among their patients.
Insurers must follow through
Back in 2018, the AMA joined the American Hospital Association, American Pharmacists Association, Medical Group Management Association, America’s Health Insurance Plans, and Blue Cross Blue Shield Association in releasing a consensus statement (PDF) on how to improve prior authorization.
Seven years later, surveyed physicians reported that health plans have made little progress honoring their commitments as outlined in that document. Major payers such as UnitedHealthcare and Cigna pledged to reduce services requiring prior authorization in 2023. But just 16% of physicians who work with UnitedHealthcare and Cigna, respectively, reported that the changes led to a reduction in prior authorization requirements.
There has been some momentum to fix prior authorization at the state and federal levels. States enacted 13 prior authorization reform bills last year to cut the volume of prior authorization requirements, reduce patient care delays, improve transparency surrounding prior authorization rules and increase prior authorization data reporting.
At the federal level, the Centers for Medicare & Medicaid Services last year issued a final rule that included prior authorization reforms designed to cut patient-care delays and electronically streamline the process for physicians.
However, the continuing resolution that Congress passed in late 2024 to keep the federal government operating into 2025 failed to include prior authorization reform in the final package—a reform with vast bipartisan support in both chambers. The AMA and others are calling for five critical reforms, including speeding up response times and maintaining continuity of care.
Patients, doctors and employers can learn more about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.
