States Move To Curb Prior Authorization Requirements

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Amid growing criticism of health insurers' onerous priorauthorization practices, lawmakers in 30 states have introduced bills this year that aim to rein in insurer gatekeeping and improve patient care. HealthcareBilling HealthcareAdministration

have introduced comprehensive reform bills that include a"grace period" of 60 days, to ensure continuity of care when a patient switches health plans. They also would eliminate repeat authorizations for chronic and long-term conditions, set explicit timelines for insurers to respond to prior authorization requests and appeals, and require that practicing physicians review denials that are appealed.

The legislation in New Jersey and other states face stiff opposition from the insurance lobby, especially state associations of health plans affiliated with AHIP. The California Association of Health Plans, for example, opposes a, introduced in February, that would allow a select group of high-performing doctors to skip prior authorizations for 1 year.

The approval rate is at least 90% for a certain number of eligible health services; but the number of prior authorizations required to qualify can range from 5 to 30, depending on the state law. "These are important reforms that will help ensure that patients can receive the care they need, when they need it," said CMA president Donaldo Hernandez, MD.

He noted that the legislation has had a limited effect for several reasons. Commercial health plans only make up only about 20% of all health plans in Texas. Also, the final regulations didn't go into effect until last May and physicians are evaluated by health plans for"gold card" status every 6 months, said Silva.

He's optimistic that if the bill becomes law, the number of physicians eligible for gold cards may increase.

 

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