Physician frustration is growing as prior authorization and other payer obstacles lead to increased retrospective payment denial.
The American Medical Association is is advocating for reforms to payer practices to address these issues, according to a Nov. 12 news release shared with Becker's.
Here are five things to know:
1. Physicians and medical students at a recent AMA meeting voted to support reform — specifically to implement a policy that would ensure that the payer vetting process guarantees payment once a service is completed.
2.Under this policy, the AMA will support a federal ban on insurers denying payment for pre-approved, medically necessary care. The AMA will also advocate for legal action against insurers that improperly recoup or deny payments after services have been rendered.
3. "Prior authorization, once granted, should be sufficient to guarantee payment," said Marilyn Heine, MD, an AMA board member, in the release. "It is unacceptable that a health plan provides a 'green light' for medically necessary care, only to then create barriers to payment. This practice is a burden on physicians, patients, and employers, causing financial strain for both practices and families."
4. AMA's advocacy has already led policymakers to work toward reform, according to the release. These reforms include CMS releasing final regulations to streamline the prior authorization process, lawmakers introducing a bipartisan version of the Improving Seniors’ Timely Access to Care Act, and over 12 states enacting laws to reduce care delays caused by prior authorization requirements.
5. ASCs and physicians in some markets have taken note of insurance companies scrutinizing even previously approved claims post-procedure. In 2024, 77% of surveyed respondents reported that payer policy changes are becoming more frequent, up from 67% in 2022, according to Experian Health's "2024 State of Claims" survey.
"All the insurance carriers are now hiring companies to look at a post-procedure type of prior authorization, or post-authorization," said Adam Bruggeman, MD, a spine surgeon at San Antonio-based Texas Spine Care Center and chief medical officer of MPOWERHealth. "Essentially you'd perform the procedure and then after the procedure, using all the same data they asked for going into surgery, they're now asking hospitals, surgery centers and doctors again to confirm that they really should have approved the surgery the first time and then they're clawing back the money, or not paying the money as a result."