Physicians Concerned AI Increases Prior Authorization Denials, Worsens Patient Harms & Waste

Reflects growing use of unregulated AI decision-making systems by health insurer industry

CHICAGO, Feb. 24, 2025 (GLOBE NEWSWIRE) -- 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 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 harms 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 major impediment to patient care for decades. More recently, health insurers have 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.

“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.” 

To that end, the AMA firmly believes that AI must augment decision-making; be referred to as “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, recently passed AMA policy identifies significant concerns with insurer use of AI.

Physicians tell the AMA that delayed and disrupted care continues to be a predictable and maddening part of the patient experience, as widespread use of prior authorization programs by the health insurance industry 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 has a negative impact on patient 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 are contributing to physician burnout while forcing scarce resources to be redirected from patient care towards 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 the number of prior authorization denials has increased somewhat or significantly over the last five years.
• Diverted Time and Resources – The prior authorization workload for a single physician 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 overall utilization of health care resources, resulting in unnecessary waste rather than cost savings. More specifically, physicians reported resources were diverted to ineffective initial treatments (77%), additional office visits (73%), urgent or emergency care (47%), and hospitalizations (33%) due to prior authorization requirements.

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 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 have 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 was closely followed by Humana (64%), Anthem/Elevance (59%), Aetna (57%), Cigna (55%), and Blue Cross Blue Shield (54%) in high burden ratings for prior authorization.

The AMA continues to work on every front to right-size prior authorization programs so that physicians can focus on managing patient care rather than administrative burdens. Patients, physicians, and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.