Physicians are recommending revising peer-to-peer reviews between healthcare providers and insurers to help ease prior authorization burdens plaguing radiologists and other members of the profession.
Such P2P discussions around the medical necessity of imaging and other healthcare services usually take place between docs employed by insurance companies and by hospitals or other healthcare entities. But sometimes, the payer representative has little knowledge of the treatment under review, the American Medical Association said Tuesday.
To address this issue, the AMA House of Delegates wants insurer-employed docs to have clinical expertise in the disease under discussion, along with knowledge of corresponding evidence-based guidelines. Physicians additionally want insurance companies to make P2P prior authorizations actionable within 24 hours of the conversation.
“Delayed and disruptive treatment due to unnecessary and bureaucratic prior authorization requirements can have life-or-death consequences for patients—something we know from data and surveys of physicians,” AMA President Susan Bailey, MD, said in a statement. “P2P reviews are another burdensome layer insurers are increasingly using without justification, and the peer reviewers are often unqualified to assess the need for services for a patient for whom they have minimal information and to whom they have never spoken or evaluated.”
Diagnostic radiology faces one of the heaviest prior authorization burdens in medicine, according to a recent study, behind only radiation oncology and cardiology. Roughly 91% of radiology services are subject to these extra reviews, the JAMA analysis of private claims found. As such, radiologists and other specialists recently lobbied the feds to pass legislation loosening red tape in Medicare Advantage.
AMA and its House of Delegates also want insurers to follow the guidance of medical societies like the American College of Radiology “where applicable.” They’re calling for a temporary suspension of all prior authorization requirements during a declared public health emergency. And the nation’s largest physician lobbying group is pushing payers not to require authorization for any medically necessary procedure related or incidental to an already-approved operation or other course of treatment.
Radiologists can read more about the new AMA policy, and contribute their own prior authorization stories at FixPriorAuth.org.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.