The AMA's Fight Against Prior Auth: Progress and Pushback

The American Medical Association has been the most prominent national voice calling for prior authorization reform. For more than a decade, the AMA has marshaled data, organized coalitions, and lobbied at both the federal and state levels to reduce the prior authorization burden on physician practices. The progress has been real but incremental, and the pushback from payers has been equally persistent.

The AMA's Case Against the Status Quo

The AMA's advocacy rests on a foundation of data collected through its annual Prior Authorization Physician Survey. The findings paint a consistent picture across survey years:

• Physicians and their staff spend an average of nearly two full business days per week on prior authorization
• 94% of physicians report that prior authorization delays access to necessary care
• More than one in three physicians report that prior authorization has led to a serious adverse event for a patient
• 80% of physicians report that prior authorization can lead to treatment abandonment
• The administrative burden has increased over the past five years according to the vast majority of respondents

These data points have become the standard citations in policy discussions about prior authorization reform. They appear in legislative testimony, regulatory comments, and media coverage of the issue. The AMA's consistent investment in generating this data has been one of its most effective advocacy tools.

The Reform Principles

The AMA, along with a coalition of more than 400 healthcare organizations, has articulated a set of prior authorization reform principles that form the basis of its advocacy agenda. These principles call for:

• Clinical validity: Prior authorization criteria should be based on current, publicly available clinical evidence and reviewed regularly.
• Continuity of care: Patients currently receiving treatment should not face interruptions due to changes in prior authorization requirements.
• Transparency: Payers should disclose their prior authorization criteria and the clinical basis for denial decisions.
• Timely decisions: Prior authorization determinations should be made within timeframes that do not delay clinically appropriate care.
• Gold carding: Physicians with high approval rates should be exempted from prior authorization requirements for services where they have demonstrated appropriate utilization.

Legislative and Regulatory Progress

At the federal level, the AMA's advocacy contributed to the CMS Prior Authorization Interoperability Rule finalized in January 2024. The rule requires CMS-regulated payers to implement electronic prior authorization, establish response time limits, and provide specific reasons for denials. While the rule does not eliminate prior authorization, it represents meaningful progress toward standardization and transparency.

The AMA has also supported federal legislation including the Improving Seniors' Timely Access to Care Act, which passed the House with overwhelming bipartisan support but stalled in the Senate. The bill would have required Medicare Advantage plans to implement electronic prior authorization, establish response deadlines, and report prior authorization data publicly.

At the state level, the AMA has supported and helped shape dozens of prior authorization reform bills. More than 30 states have enacted some form of prior authorization reform legislation, with provisions ranging from gold-carding programs to response time requirements to continuity of care protections. Texas, West Virginia, Michigan, and Louisiana have been among the most active states in this area.

Payer Pushback

The insurance industry has resisted many of the AMA's reform proposals, arguing that prior authorization is necessary to control costs, ensure appropriate utilization, and protect patients from unnecessary procedures. America's Health Insurance Plans (AHIP), the primary trade association for health insurers, has acknowledged the need for process improvements but has pushed back against legislative mandates that would restrict payers' ability to manage utilization.

Payers have pointed to their own investments in electronic prior authorization and process streamlining as evidence that the industry is self-correcting. They have also argued that gold-carding requirements could undermine the utilization management programs that keep premiums affordable for consumers.

This tension between provider advocacy and payer resistance has defined the pace of reform. Progress comes in increments — a state law here, a federal rule there — rather than in sweeping changes to the prior authorization system.

What It Means for Practices

The AMA's advocacy has produced tangible results, but the timeline for comprehensive reform is measured in years, not months. The CMS rule's electronic PA requirement does not take full effect until 2027. State laws vary widely in scope and enforcement. And commercial payers not regulated by CMS may not be directly affected by federal rules.

For individual practices, the practical implication is clear: systemic reform is coming, but it is not coming fast enough to solve today's operational challenges. Practices need to build efficient prior authorization and denial management processes now, while the policy landscape continues to evolve. The AMA's advocacy is creating the conditions for a better future, but practices cannot wait for that future to arrive before addressing the burden they face today.