Another increasing practice by insurers is changing existing health plans mid-year in a contract. All over the country, physicians are seeing stable patients require prior authorization for medications they have already been receiving. Health plans justify this action because businesses that provide health insurance for their employees are constantly seeking to reduce costs, hence the mid-year plan changes. Employees are having more of their insurance costs shifted to them and away from their employers.
Electronic Prior Authorization
State legislatures are realizing the problems created by an overly burdensome utilization review process and adopting electronic prior authorization (ePA). According to Point of Care Partners, 15 states require health plans to support some type of ePA submission, which includes web-based portals. These laws require a standard form that is updated and reviewed by stakeholder groups and maintained by the state’s commissioner of insurance. Some include deadlines by which the insurer must respond to appeals in addition to why the claim was denied. Laws passed in both Ohio and Delaware include these requirements. Ohio requires all health plans to respond to a prior authorization in 48 hours for urgent care services and 10 calendar days for any request. Delaware requires a two-business-day response for drug requests, 48 hours for urgent requests, three days for health services if electronically submitted and five days for health services that are not electronically submitted.
An additional win with the Ohio law: Any change to an insurance plan must be preceded by a 30-day notice to the provider. This helps eliminate the guessing game physicians have to play when deciding on a course of treatment. Knowing the policies ahead of time further empowers physicians to deliver care to their patients without delays.
Mandating support for ePA is significant because multiple studies have shown that ePA is a much more economical and efficient means of submitting information. Although ePA reform does not eliminate all the problems associated with utilization review, it does begin to reduce the amount of resources physicians must expend on behalf of their patients.
What You Can Do
Physicians must continuously support advocacy efforts by their state and specialty societies. In all states that have reformed their prior authorization laws, the state medical society has taken the lead. These policies affect every specialty in medicine. Being involved with your state society ensures the unique problems your rheumatology practice faces are addressed when drafting these laws.
Additionally, the more rheumatologists who are members of the AMA, the more the College can push rheumatology issues to the forefront across the country. We request that all ACR members either renew their membership or join the AMA to continue to allow the ACR to leverage its advocacy activities utilizing the AMA’s ability to convene groups to address our common needs, as well as its significant advocacy activities.
