APTAMD is part of a coalition that has drafted new legislation to address administrative burden and delays with prior authorizations.

Health Insurance – Utilization Review – Revisions (SB791 |HB0932)

Status
– Both hearing were held in February. We should have an update late March 2024.
– Over 200 APTAMD members joined us for advocacy day on Feb. 7th to educate legislators and share the importance of this legislation.

Synopsis
Altering and establishing requirements and prohibitions related to health insurance utilization review; altering requirements related to internal grievance procedures and adverse decision procedures; altering certain reporting requirements on health insurance carriers relating to adverse decisions; and establishing requirements on health insurance carriers and health care providers relating to the provision of patient benefit information.

This legislation will improve the prior authorization process by adding transparency, aligning standards and increasing accountability of the insurers See APTA Infographic.

Health insurance carriers engage in a process known as “utilization review,” which is a system where the carrier reviews a practitioner’s request that a patient receive a certain health care service to determine if the service is medically necessary. The two most common types are “prior authorization,” which is requesting approval in advance from the carrier and “step therapy,” where the patient must try and fail on other medications (often less expensive) before “stepping up” to another medication.

This legislation would reform prior authorization by:

1. Require evidence-based, peer reviewed criteria as the standard of care developed by an organization that works directly with health care providers or a professional medical specialty society.
2. Mandate that a physician which made or participated in the adverse decision notify the insured’s physician or health care practitioner prior to making the adverse decision and be available to discuss the basis for the denial and the medical necessity of the health care service rather than deny care and then allow for a peer-to-peer meeting after the fact.
3. Study how to standardize electronic systems across all carriers (rather than each carrier having their own system) with the same data points and using a single point of entry, such as CRISP.
4. Study the feasibility of implementing a “gold card” standard in Maryland, which would exempt health care practitioners who meet certain standards from prior authorization standards.

The Data –Ultimate Outcome of Denied Claims
■ 13.08% of filed claims are denied
■ 66.14% of denied claims are appealed
■ 52.34% of appealed denials are overturned

Sponsors
House of Representatives: Delegate Bonnie Cullison Assigned to: Health and Government Operations

Senate: Senator Katherine Klausmeier Assigned to: Senate Finance Committee