In late October, Pennsylvania state lawmakers sent a bill aiming to streamline the prior authorization process to the governor's desk, making it one of several states that have taken steps to reform that process this year.
Here is what Pennsylvania and two other states have done in 2022:
Michigan: In April, Gov. Gretchen Whitmer signed the Health Can't Wait Act, which shortens the time payers have to consider prior authorization requests and requires payers to provide more information to the public and providers regarding the prior authorization process.
Four provisions of the new law:
- Prior authorization requirements from payers must be published on the payer's website in detail and in easily understandable language. Aggregated information about prior authorization approval and denials must also be made publicly available.
- Payers must base their prior authorization requirements on clinical, evidence-based criteria established with input from practicing physicians.
- Clinical review criteria is based on current peer-reviewed evidence. Individuals with a financial stake in the outcome of prior authorization decisions are banned from the decision-making process.
- All prior authorization requests must be acted upon in a timely manner. Clinicians and patients must be properly notified of new or amended prior authorization requirements.
Texas: The effects of the state's "gold card" law passed in 2021 kicked in Oct. 1. Under the law, physicians who have a 90 percent prior authorization approval rate over a six-month period on certain services are exempt from prior authorization requirements for those services.
Gold cards are granted per plan, per procedure. Providers and physicians do not apply for the cards. Rather, health plans run an evaluation to see if the providers meet the 90 percent threshold, and the plans are responsible for notifying the provider of whether they qualify.
After each six-month review period, new providers or new services for existing providers are added or removed based on the results.
The law applies to Texas in-network physicians and providers serving fully insured, commercial business in the individual, small and large group markets.
Pennsylvania: If signed into law, Pennsylvania's bill would require insurers to provide timely approval for nonurgent and emergency healthcare services to physicians before services and treatment plans are rendered.
It would also create a timely process for appeals determinations, and if an insurer questions the necessity of a service, the bill calls for a peer review by a physician from the specialty in question. It would also create an electronic portal with all prior authorizations and accompanying paperwork flowing into one site.
The bill would also create streamlined step therapy guidelines for prescription drugs and new options to obtain exemptions to best treat the medical condition of the patients.