By Susan Rupe
Prior authorization has become a hot-button issue in health care, and the National Council of Insurance Legislators will tackle the issue at its annual meeting in November.
A draft of NCOIL’s Prior Authorization Reform Model Act received comment at a meeting Friday prior to being presented at NCOIL’s annual meeting.
The purpose of the act is to protect the health care professional-patient relationship from unreasonable third-party interference; prevent prior authorization programs from hindering the independent medical judgment of a physician or other health care provider; and to ensure the transparency of a fair and consistent process for health care providers and their patients.
The act would apply to every health insurance issuer and all health benefit plans, and all private review agents and utilization review plans, except for employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974 or health care provided pursuant to the Workers’ Compensation Act.
Provisions of the act include clinical review criteria to determine whether a service will be covered. That clinical review criteria must be consistent with nationally accepted standards generally recognized by physicians and health care providers practicing in relevant medical and clinical specialties except where state law provides its own standard. In addition, criteria must ensure quality of care and access to needed health care services as well as be evidence-based on sources including peer-reviewed scientific studies.
Prior authorization info must be posted online
Health insurers that use prior authorization must post information about approvals and denials on their websites. If prior authorization is denied, the insurer must give the patient and the health care provider the reasons for the denial and related evidence-based criteria, the right to appeal the denial and instruction on how to file the appeal.
The insurer also must make sure all appeals are reviewed by a physician or a physician’s representative.
The model law “is a fantastic piece of legislation,” said Terry Cunningham, senior director at the American Hospital Association. But he suggested a few revisions, including requiring a trained clinician to all denials, not only the ones that are appealed. In addition, he suggested requiring all prior authorization requests for post-acute care to be urgent.
In July, AHIP submitted a letter to NCOIL in which its members committed to streamline and simplify prior authorization. Participating health plans committed to standardizing electronic prior authorization, enhancing transparency on determinations and ensuring medical review of prior authorization denials.