AMA Seeks More Oversight of Prior Authorization Artificial Intelligence

During its recent Annual Meeting, the American Medical Association (AMA) House of Delegates adopted a policy calling for increased regulatory oversight of health insurers’ use of artificial intelligence in the prior authorization process.

The new policy urges payers to ensure that their practices for reviewing patient claims and prior authorization requests are thorough and fair. The AMA suggests that these processes be based on clinical criteria and include reviews from healthcare professionals with expertise in the service being reviewed and no incentives to deny care.

Additionally, the new policy seeks for payers to require a human examination of a patient's records prior to any care denial.

The recommendations come as the AMA works to navigate the challenges of prior authorization automation. The press release states that the organization largely supports automation to ease clinician burden and speed up prior authorizations, but believes prior authorization is inefficient, costly, overused, and to blame for significant patient care delays.

"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, in the press release. “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.”

In an AMA news article further detailing the policy, it is indicated that the organization will “continue to conduct research on the costs associated with prior authorization by utilizing AMA and other data sources.”

This policy is the AMA’s latest work to drive prior authorization reform as part of its Recovery Plan for America’s Physicians. Under the plan, the AMA is working to combat physician burnout and scope creep while improving prior authorization and patient care.

Prior authorization has become a thorny issue for providers and payers in recent years.

Last month, AMA survey data showed that prior authorization is escalating administrative burdens for clinicians and disrupting care continuity for patients.

Some stakeholders have promoted the use of AI and automation to address these challenges, and multiple payers have adopted these strategies.

In February of last year, Florida Blue, a subsidiary of GuideWell, became the first US payer to automate prior authorization approvals in an effort to speed up the process while improving provider and patient satisfaction.

The payer partnered with health technology company Olive to shift prior authorization decision-making to the point of care using an AI-powered clinical review tool.

This shift is designed to help reduce administrative burdens for care teams while ensuring that patients receive the right care at the right time, and the AI’s full-scale implementation for over 2.5 million members was set to go live in July 2022.