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33 PA Health Care Groups Agree: Reform Insurance Prior Authorization Practices

July 24, 2019

In HAP’s latest blog, President and CEO Andy Carter shares how a coalition of 33 health care organizations that represent Pennsylvania providers is calling for commonsense reforms to protect against prior authorization red tape that can keep patients from getting the health care they need when they need it.

Prior authorization is the insurance practice of requiring a health care provider to obtain advance approval from a health plan before a specific procedure, service, device, supply, or medication can quality for coverage by that plan when that care is delivered to the patient. Other terms used by health plans for this process include “preauthorization,” “precertification,” “prior approval,” “prior notification,” “prospective review,” and “prior review.”

Health insurance plans instituted the use of prior authorization requirements to keep health care costs under control. But providers have continued to experience an increasing number of scenarios where prior authorization has caused significant delays in the delivery of timely and appropriate care for patients for commonly prescribed drugs and services.

The coalition is calling on Pennsylvania to join 14 states that have enacted reforms to improve the prior authorization process. HAP-supported House Bill 1194, sponsored by Representative Steven Mentzer (R-Lancaster) would to provide commonsense protections that would require insurers to:

  • Make timely decisions, especially after business hours and on weekends
  • Use step therapy protocols based on clinical guidelines developed by independent experts
  • Cover and pay claims for care that could not be pre-authorized because it became necessary during the course of a pre-authorized test, treatment, or procedure
  • Share publically on their websites percentages of prior-authorization approvals and denials by type of insurance for Pennsylvania

HAP has developed a fact sheet on the topic, “Reforming Prior Authorization; Protect Patient Access to Timely Care,” that outlines important information about increasing prior authorization delays and denials and the impact on quality.

For more information, please contact Kate Slatt, HAP’s senior director, innovative payment and care delivery, or Stephanie Watkins, HAP’s vice president, state legislative advocacy.

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