With recent advances in augmented intelligence (AI), the American Medical Association (AMA) House of Delegates adopted policy during its Annual Meeting calling for greater regulatory oversight of insurers’ use of AI in reviewing patient claims and prior authorization requests. While the AMA supports automation to speed up the prior authorization process and cut down on the burdensome paperwork required by physicians, the fact remains that prior authorization is overused, costly, inefficient, and responsible for patient care delays.
The newly adopted policy calls for health insurers utilizing AI technology to implement a thorough and fair process that is based on clinical criteria and includes reviews by physicians and other health care professionals with expertise for the service under review and no incentive to deny care. ProPublica revealed that over a period of two months in 2022, Cigna doctors denied more than 300,000 claims as part of a review process that used artificial intelligence, with Cigna doctors spending an average of 1.2 seconds on each case. The new AMA policy calls for insurers to require a human examination of patient records prior to a care denial.
"The use of AI in prior authorization can be a positive step toward reducing the use of valuable practice resources to conduct these manual, time-consuming processes. But AI is not a silver bullet,” said AMA Board Member Marilyn Heine, MD. “As health insurance companies increasingly rely on AI as a more economical way to conduct prior authorization reviews, the sheer volume of prior authorization requirements continues to be a massive burden for physicians and creates significant barriers to care for patients. The bottom line remains the same: we must reduce the number of things that are subject to prior authorization.”
The AMA has long advocated for prior authorization reform and the issue is a top priority in the Recovery Plan for America’s Physicians. A majority of U.S. states are now considering legislation to “right size” the payer practice of prior authorization. Nearly 90 prior authorization reform bills were recently introduced in 30 states and more than a dozen are still being considered for passage. The AMA continues to work toward a reform plan that will lessen the overall volume of prior authorizations, increase transparency of requirements, promote automation, and ensure timely care for patients.