For decades, California physicians have battled excessive and often unnecessary prior authorization requirements that delay care, increase administrative burdens, and place patients at risk. Now, with the growing use of unregulated artificial intelligence (AI) in health insurance decision-making, these challenges are escalating. The California Medical Association (CMA) is leading the charge to combat these harmful practices with a robust legislative reform package aimed at ensuring timely and necessary medical care for patients while reducing the administrative strain on physicians.
The Growing Threat of AI-Driven Prior Authorization Denials
Many physicians fear that health insurers’ reliance on AI-powered automation and predictive algorithms is systematically overriding medical judgment, leading to inappropriate denials of necessary care. According to a new survey from the American Medical Association (AMA), 61% of physicians are concerned that AI is increasing prior authorization denials, exacerbating patient harm, and generating unnecessary costs.
Health insurers have increasingly turned to AI-driven tools to issue prior authorization decisions with little or no human oversight. These systems have been found to generate denials at rates up to 16 times higher than traditional methods. Physicians and patient advocates alike argue that AI should enhance decision-making, not replace the medical expertise that ensures patients receive the care they need.
“Using AI-enabled tools to automatically deny more and more needed care is not the reform of prior authorization that 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 Impact on Physicians and Patients
Delayed Care: 93% of physicians report prior authorization delays.
Patient Harm: 29% say these delays have caused severe adverse events, including hospitalization and death.
Increased Denials: AI-driven systems deny care 16 times more than traditional methods.
Burnout: 89% of physicians say prior authorization worsens burnout, with 39 requests per week consuming 13 hours of physician time.
Treatment Abandonment: 82% of physicians report patients abandoning care due to prior authorization struggles.
CMA’s Legislative Solutions
CMA’s legislative prior authorization reform package would implement common-sense reforms to streamline the prior authorization processes, expedite critical care for patients and free up physicians’ time to focus on patients, not paperwork. The legislative package includes:
AB 510 (Addis): Requires that appeals of prior authorization denials be performed by a provider of the same or similar specialty. This will help ensure that providers can discuss prior authorization denials with a professional peer who understands the recommended treatment and underlying condition.
AB 539 (Schiavo): Extends the validity of an approved prior authorization to one year (current industry standard is between 60-90 days). This will provide patients with a longer window of time to receive medically necessary care and avoid cumbersome prior authorization review (and ultimately appeal) processes.
AB 512 (Harabedian): Requires health plans to respond to urgent prior authorization requests within 24 hours and respond to nonurgent requests within 48 hours. Currently, health plans have 72 hours for urgent and five days for nonurgent requests. This change will ensure more patients can receive care in a timely fashion, consistent with the urgency of their condition or can swiftly appeal any denials, if necessary.
SB 306 (Becker): Requires health plans to remove the requirement for prior authorization from any service that they approve more than 90% of the time. This will reduce the overall volume of prior authorization requests and ensure that patients can receive the care they need with minimal delay and physicians can spend more time focusing on patient care.
How LA Physicians Can Help
Share Stories: Report cases where prior authorization delays have harmed patients.
Advocate: Contact legislators to support CMA’s reforms.
Educate Patients: Direct them to FixPriorAuth.org to share experiences and push for change.
CMA and LACMA remain committed to restoring physician-led decision-making and protecting patient care. Stay informed at www.cmadocs.org.
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