AMA works to right-size prior auths 

ORLANDO, Fla. – The American Medical Association will consider legislative and legal actions to fight retrospective denial of payment for care that has been pre-certified by an insurer. 

A 700-member House of Delegates has approved a new policy that directs the AMA to support a federal prohibition on the inappropriate denial of payment for medically necessary care that has been pre-certified by insurers and encourages the association to take legal action against insurers that engage in appropriate post-service payment denials and payment recoupment. 

“Prior authorization, once granted, should be sufficient to guarantee payment,” said AMA Board Member Marilyn J. Heine, M.D. “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.” 

The AMA’s FixPriorAuth.org grassroots campaign and sustained advocacy have led to federal and state policymakers working toward prior authorization reforms in 2024 that include:  

• CMS released final regulations making important reforms to prior authorization to cut patient care delays and electronically streamline the process for physicians. 
• Lawmakers in June introduced an updated, bipartisan version of the Improving Seniors’ Timely Access to Care Act in both the House of Representatives (H.R. 8702) and Senate (S. 4532). 
• Over a dozen states enacted laws this year supported by the AMA and state medical associations that reduce care delays and wasted time experienced by patients and physicians due to prior authorization requirements.