Physicians Warn AI-Powered Insurance Denials Harm Patients and Undermine Care

Many physicians fear the health insurance industry’s use of unregulated artificial intelligence (AI) automation and predictive technologies will increasingly override good medical judgment and systematically deny patients coverage for necessary medical care. According to a new survey (PDF) from the American Medical Association (AMA), three in five physicians (61%) are concerned that health plans’ use of AI is increasing prior authorization denials, exacerbating avoidable patient harm, and escalating unnecessary waste now and into the future.

Burdensome prior authorization requirements that conflict with evidence-based clinical practices and create hurdles to patient access to safe, timely, and affordable treatment have been a significant impediment to patient care for decades. Health insurers have recently turned to AI decision-making tools that generate prior authorization decisions with little or no human review. These AI tools have been accused of producing high rates of care denial—in some cases, 16 times higher than is typical (PDF).

“Using AI-enabled tools to automatically deny more and more needed care is not the reform of prior authorization physicians and patients are calling for,” said AMA President Bruce A. Scott, M.D. “Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care. Medical decisions must be made by physicians and their patients without interference from unregulated and unsupervised AI technology.”

The AMA firmly believes that AI must augment decision-making, be called “augmented intelligence,” and not remove humans from patient care, coverage, or treatment.

Notably, the AMA’s Augmented Intelligence Research, released earlier this month, found that nearly half of all physicians (49%) ranked oversight of payers’ use of AI in medical necessity determinations among the top three priorities for regulatory action. Moreover, a recently passed AMA policy (PDF) identifies significant concerns with insurers’ use of AI.

Physicians tell the AMA that delayed and disrupted care continues to be a predictable and maddening part of the patient experience. The health insurance industry’s widespread use of prior authorization programs persistently impedes the delivery of necessary medical treatments, jeopardizes quality care, and harms patients.

• Patient Harm – More than one in four physicians (29%) reported that prior authorization has led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment, or death.
• Poor Outcomes—More than nine in 10 physicians (94%) reported that prior authorization negatively impacts clinical outcomes.
• Delayed Care - More than nine in 10 physicians (93%) reported that prior authorization delays access to necessary care.
• Disrupted Care - More than four in five physicians (82%) reported that patients abandon treatment due to authorization struggles with health insurers.
• Shifted Costs- Four in five physicians (80%) reported that prior authorization delays or denials “at least sometimes” make patients pay out-of-pocket for medications.
• Lost Workforce Productivity - More than half of physicians (58%) who cared for patients in the workforce reported that prior authorizations have impeded a patient’s job performance.

The substantial burdens associated with navigating the prior authorization process and fighting denials contribute to physician burnout while forcing scarce resources to be redirected from patient care toward administrative tasks.

• Added Burden - Physicians reported completing an average of 39 prior authorizations per week, and nearly one in three physicians (31%) reported that prior authorization requests are often or always denied.
• Physician Burnout - Nearly nine in 10 physicians (89%) reported that prior authorization somewhat or significantly increases physician burnout.
• Denial Trend – Three-quarters of physicians (75%) reported that prior authorization denials have increased somewhat or significantly over the last five years.
• Diverted Time and Resources—A single physician’s prior authorization workload consumes 13 hours of physician and staff time each week, and two in five (40%) physicians employ staff members to work exclusively on tasks associated with prior authorization.

Not only does prior authorization negatively impact patient-centered care and add to crushing administrative burdens on physicians, but the AMA survey found it also results in significant waste and unnecessary costs across the entire health system.

• Wasted Health Resources - More than four in five physicians (88%) reported that prior authorization requirements lead to higher utilization of health care resources, resulting in unnecessary waste rather than cost savings. Physicians reported that prior authorization requirements diverted resources to ineffective initial treatments (77%), additional office visits (73%), urgent or emergency care (47%), and hospitalizations (33%).

Despite mounting evidence that prior authorizations for drugs and medical services can be a hazardous and burdensome obstacle to patient-centered care, the AMA survey found the health insurance industry continues to show ineffectual follow-through on five key reforms (PDF) that were mutually agreed to in January 2018 by the AMA and other national organizations representing pharmacists, medical groups, hospitals, and health insurers.

While UnitedHealthcare (UHC) and Cigna announced reductions in the number of services that require prior authorization in 2023, only 16% of physicians who work with UHC and 16% of physicians who work with Cigna reported that these changes had reduced the number of prior authorizations completed for these plans. In addition, physicians reported consistently high administrative burdens across all major health insurers when complying with prior authorization requirements. Physicians ranked UHC as the insurer with the most prior authorization hassles, with 72% of physicians giving UHC a “high” or “extremely high” burden rating. UHC closely followed Humana (64%), Anthem/Elevance (59%), Aetna (57%), Cigna (55%), and Blue Cross Blue Shield (54%) in receiving high burden ratings for prior authorization.

Patients, physicians, and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.