Just 15% of physicians say that prior authorization "peers" deserve that title, according to an Aug. 30 survey by the American Medical Association.
The 2023 AMA prior authorization survey included responses from 1,000 physicians from a wide range of practice settings.
Sixty-one percent of physicians reported that they sometimes must participate in peer-to-peer reviews during the prior authorization process in order to get approval for medication or procedures they say are medically necessary for their patients.
While many find the process frustrating, as it adds administrative burden, many physicians become incensed when they discover the "peer" they work with through the insurance company is often not a peer at all. Only 15% of respondents said that the payer-appointed peer "often" or "always" has the appropriate qualifications. More than one-third said that payer peers "rarely" or "never" have the expertise required to make a call on their patients prior authorization.
This means that specialists are often paired with "peers" outside their field, further complicating an already arduous process for many physicians.
AMA President Bruce Scott, MD, an otolaryngologist in private practice in Louisville, Ky., shared his frustrations regarding prior authorization and "peer" reviews in a June 18 Leadership Viewpoints column.
"I sit down with a patient, listen to their history, do a thorough exam, review imaging studies and then together we decide on a treatment plan," Dr. Scott wrote. "But then I have to get approval from an insurance company representative who has never seen my patient and who typically isn't even a physician. Never mind an otolaryngologist who could best understand the prescribed course of treatment; it's rare the person on the other line can even pronounce otolaryngology."