Prior authorization bill would standardize process for greenlighting Pennsylvania health care

(The Center Square) – Health care in Pennsylvania could get simpler with a bill that would streamline and standardize the process for prior authorization, which ensures that a health plan covers a procedure or service.

Prior authorization requires approval from the health plan in advance of the service, and long delays for this authorization can make health problems worse or deter patients from seeking care. It’s also known as preauthorization, preapproval, or precertification.

“As implemented currently in the Commonwealth, the prior authorization procedure is too often an inefficient process that increases costs for providers, their patients and all policy holders,” Sen. Kristin Phillips-Hill, R-York, wrote in a legislative memo for Senate Bill 225.

To change that, the bill would provide a standard definition of prior authorization, require providers to accept requests electronically, and send approvals or denials of authorization electronically.

New disclosure requirements about prior authorization will also be created along with requirements for consistent response times. The goal is to improve patient experience and make the health care system less complicated for the public.

“Patients will see a streamlined process that will cut down on waiting times for approval from insurers to their health care provider to render services or perform operations,” Phillips-Hill said in an email. “Too often, I hear from patients and providers about delays in treatment, leading to greater frustration which inevitably leads to poor outcomes.”

The goal with a simpler prior authorization process is to “cut down on the back-and-forth” with a doctor or hospital and health insurance companies for better outcomes, Phillips-Hill noted.

Prior authorization has been used as a way to keep down costs and ensure a health insurance plan covers the relevant care, but it’s also an administrative burden. A 2021 American Medical Association survey of doctors found that 93% reported care delays due to prior authorization. Another 91% said it had a “somewhat or significant negative impact” and 88% said prior authorization had a high or extremely high burden.

State laws on prior authorization vary widely. A chart from the American Medical Association shows the complexity of prior authorization, but 22 states have some level of standardization, either partially for drug prescriptions or for services as well. Response times for authorization requests also vary widely, from 24 hours for emergency situations to 15 days in non-urgent situations.

On the federal level, the No Surprises Act of 2020 extended federal consumer protections for out-of-network bills for emergency care.

SB225 was passed by the Pennsylvania Senate on June 29 and was referred to the House Insurance Committee on June 30. Phillips-Hill is hopeful it will appear on the governor’s desk in the fall.

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