A growing number of physicians are voicing concerns about the increasing role of artificial intelligence (AI) in health insurers’ prior authorization processes. The American Medical Association’s (AMA) latest 2024 AMA Prior Authorization Physician Survey highlights that many warn AI-driven prior authorization denials are exacerbating patient harm and physician burnout.
The survey, which included 1,000 practicing physicians (400 primary care and 600 specialists), found that 61% are worried that AI-driven prior authorization denials are leading to more denials overall, while 75% reported a rise in prior authorization denials over the past five years. The findings indicate that insurers’ growing reliance on unregulated AI tools may be systematically preventing patients from receiving necessary care.
AI, Prior Authorization, and Patient Harm
Prior authorization has long frustrated physicians due to delays in treatment, but AI-driven decision-making adds a new layer of concern, specifically regarding AI-driven prior authorization denials. Many AI systems generate authorization decisions with little or no human oversight, potentially leading to an increase in these denials without clear justification or recourse. Key survey findings include:
- Patient harm: 29% reported serious adverse events, including hospitalization, permanent impairment, or death.
- Poor outcomes: 94% stated that prior authorization negatively impacts clinical outcomes.
- Delayed care: 93% said prior authorization causes treatment delays.
- Disrupted treatment: 82% noted that prior authorization leads to treatment abandonment.
- Financial burden: 80% reported that delays force patients to pay out-of-pocket for medications.
- Workforce impact: 58% observed that prior authorization impairs patients’ job performance.
AMA President criticized the use of AI for mass denials, stating, “Medical decisions should be made by physicians and their patients, not by unregulated AI algorithms that block access to care.”
Administrative Burdens and Burnout
The survey also highlighted the administrative toll of prior authorization on healthcare practices:
- Physicians complete an average of 39 prior authorizations per week, consuming 13 hours of staff time.
- 31% reported that prior authorization requests are often or always denied, requiring appeals that further strain resources.
- 40% of physicians employ dedicated staff to handle prior authorization tasks.
- 89% said prior authorization contributes to physician burnout.
- 65% are required to participate in lengthy peer-to-peer reviews with insurers.
Despite insurers’ claims of reducing prior authorization requirements, physicians report little improvement. Among those working with UnitedHealthcare (UHC) and Cigna—two of the largest U.S. health insurers—only 16% noticed a decrease in prior authorization requests. UHC ranked as the insurer with the highest prior authorization burden.
Call for Regulatory Oversight
Physicians overwhelmingly support greater oversight of AI use in prior authorization, with 49% ranking it among their top three policy priorities. The AMA is advocating for AI to augment human decision-making rather than replace it, ensuring that medical necessity determinations prioritize patient health over cost-cutting algorithms.
AI-Driven Prior Authorization Denials: A Game-Changer for Denial Management Companies
AI-driven prior authorization (PA) denials are crucial for denial management companies, as they help reduce administrative burdens, improve efficiency, and maximize reimbursement. The traditional PA process is time-consuming and prone to errors, leading to delays in patient care and revenue loss. AI-powered solutions streamline this process by automating data extraction, analyzing historical denial patterns, and predicting potential denials before claims submission.
By leveraging machine learning and natural language processing (NLP), AI-driven systems can identify missing documentation, flag high-risk claims, and provide real-time recommendations to improve approval rates. These predictive insights enable denial management teams to take proactive measures, reducing the likelihood of denials and minimizing rework.
Additionally, AI enhances communication between providers and payers by facilitating real-time authorization checks, improving transparency, and reducing back-and-forth interactions. This results in faster approvals and fewer claim resubmissions.
For denial management companies, integrating AI-driven prior authorization solutions translates into higher efficiency, reduced operational costs, and improved financial outcomes for healthcare providers. As payers continue to implement stricter authorization requirements, AI-driven technology is becoming a necessity to stay competitive and ensure seamless revenue cycle operations.