MONTGOMERY, Ala. — A total of 30 health care groups have joined the Medical Association of the State of Alabama in its effort to push to reform health insurance prior authorization requirements, which the organization says leads to higher health care costs, worsening diseases or death.
The effort is part of MASA’s “Fix Prior Authorization” campaign, which it launched last August to combat delays in treatment, service or medication by health insurance providers.
“We can no longer let paperwork and red tape stand in the way of effective medical care,” William Kilgo, the director of the Neuroimmunology and MS Clinic at USA Health in Mobile, said in a statement. “Patients like mine deserve better.”
According to a 2023 survey by the American Medical Association, 94% physicians indicated that prior authorization, the process by which physicians are required to receive health insurance companies’ approval before providing medical service, had delayed their patients’ care. Of the 1,000 physicians surveyed, 24% reported that prior authorization delays caused direct harm to patients.
Amanda Williams, MASA president and a Montgomery based physician specializing in psychiatry, told Alabama Daily News that dealing with prior authorizations often takes up as much as a fifth of her work day, and frequently causes delays in care.
“A patient who I wrote a cheap, generic medication for (to) take a tab and a half, the insurance company did not want to pay for more than one tab a day for this medication; it’s a waste of the patient’s time and my time for me to figure out what they will cover,” Williams told ADN.
“Things like that are all day, every day, and those are just the mundane tasks. Then there are the more serious things where you have a patient who needs to be in a hospital or needs a particular medication that is urgent, and those things are delayed.”
As part of its campaign, MASA has outlined 11 specific policy reforms it’s advocating for health insurance companies to consider enacting, including prohibiting repeat prior authorizations for patients with chronic conditions, prohibiting retroactive denials after prior authorization approval, and requiring the annual publication of data related to prior authorization denials and approvals.
The organization is also advocating for health insurance companies to enact a 24-hour response time for prior authorization requests for urgent care, and 48 hours for non-urgent care. Existing state law only requires health insurance providers to respond to prior authorization requests within two business days, regardless of if the care is urgent or non-urgent.
Another policy reform MASA is advocating for is to ban the sole use of artificial intelligence in making initial prior authorization determinations, which has become increasingly common among health insurance companies, a U.S. Senate Committee report found last October.
Blue Cross Blue Shield of Alabama, which holds 92% of the health care insurance market in the state, does not employ the use of AI in its prior authorization claim decisions, as other organizations in Massachusetts, Florida and California, have.
The nonprofit has been meeting with insurance companies regarding its list of prior authorization reform priorities, with a MASA spokesperson telling ADN the organization was “optimistic progress can be made without the need for legislation.”
Sophie Martin, a spokesperson for BCBS, confirmed that they had been working with MASA to address the organization’s concerns.
“We have been working with the association to share information and provide clarity, with the goal of finding common ground where possible to ensure safe, appropriate, and cost-effective care for Alabamians,” she told ADN in an email.
Williams said because of its size, BCBSA “really sets the tone” for the state.
“In a lot of ways, they do wonderful things that are great for Alabama and great for our patients and physicians, but really, with all of that power comes a lot of responsibility, and I think a lot of physicians get frustrated because there’s only one (provider), and a lot of what you can and can’t do is dictated by something you have no control over,” she said.
“As physicians, we want to provide the highest quality care modern medicine can provide; what we are encountering, however, is a level of scrutiny so severe – and a system so difficult to work within – that it becomes almost impossible to provide excellent patient care,” said Harry McCarty, a doctor with Alliance Cancer Care of Huntsville.
“There is literally almost nothing in medicine that is a bigger impediment to patient care than these barriers put up by the very health plans that are supposed to be helping us serve our patients.”