Prior authorization bill goes to Ways & Means

Substitute Senate Bill 6404 passed in the Senate Health & Long-Term Care Committee this week and was referred to the Ways & Means Committee, sending the legislation along before the Feb. 11 cutoff for bills passing through fiscal committees this legislative session.

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The bill increases transparency on prior authorization, which refers to the requirement that a medical provider gets approval from a patient’s health insurance plan to prescribe a certain medication or treatment. 

“Outside of the high cost of premiums and deductibles, the number one complaint is arguing with insurance carriers about necessary procedures,” Sen. David Frockt (D-46th District) said. “Consumers are not being approved and are routinely denied. For commercial carriers, we have no data or transparency at all.”

SSB 6404 aims to reduce barriers to patient care through adoption of appropriate use criteria for prior authorization, and by requiring carriers to submit information to the state’s insurance commissioner about prior authorization practices. The bill would also establish a work group that would review prior authorization standards and make recommendations to the legislature. 

The bill would remove the requirement for carriers to report to the Office of the Insurance Commissioner (OIC) all services covered by that carrier and would impose a requirement that carriers report lists of 10 inpatient and 10 outpatient medical or surgical services. These services would be the services with the most prior authorization requests, the services with the most approved prior authorization requests and the services with the most prior authorization request denials, but were later approved after appeal. The bill also requires carriers to submit data every year to the OIC, among other provisions of the bill. 

The substitute bill removes a requirement that would have the OIC adopt the prior authorization standards put forward by the work group established by the bill. The requirement that Medicaid, Public Employees and School Employees Benefits Boards, and carriers adopt the standards was also stricken from the substitute. 

“We worked with the hospital association on this and scaled back parts of the bill quite a bit,” Frockt said Friday. “There were objections from many.”

If the bill is passed, carriers would have to report certain prior authorization data to the OIC for the 2019 plan year by Oct. 1, 2020. By Jan. 21, 2021, the work group has to pick at least five medical and surgical providers for review if those providers use prior authorization.

Prior authorization bills have come up before the legislature in the last few years. In 2014, the legislature passed a bill that required a work group to make prior authorization recommendations to the OIC. A draft of the rules recommended by that work group was released in June 2015. 

Three years after the work group recommendations were released, the state legislature barred health carriers from requiring prior authorization for certain medical treatment visits, including evaluation and management visits, according to the SSB 6404 bill analysis.