health care technology
How interested are state insurance regulators in doing something new about health insurers' and health plans' prior authorization procedures?
A panel of regulators at the National Association of Insurance Commissioners may have shown just how concerned its members, and interest groups, are about the topic by putting 166 pages of prior authorization background materials in a packet for an upcoming in-person session.
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The panel, the NAIC's Regulatory Framework Task Force, will be holding the session at the NAIC's upcoming meeting in Indianapolis.
The speakers on the agenda come from the NAIC itself, the American Medical Association, the Leukemia & Lymphoma Society, the HIV+Hepatitis Policy and America's Health Insurance Plans.
The meeting packet includes a 122-page summary of existing state prior authorization laws.
Heather McComas, director of administrative simplification initiatives at the AMA, is briefing insurance regulators on her group's ideas, which include a 24-hour prior authorization response time limit for urgent care and a 48-hour limit for other types of care; requirements that denials be made by a physician in the same specialty as the physician recommending the care; and increased collection and reporting of prior authorization review results data.
The representatives from the Leukemia & Lymphoma Society and HIV+Hepatitis Policy are asking state insurance regulators to publish more of the prior authorization review program tracking data that they already gather through the NAIC's existing NAIC Market Conduct Annual Statement program.
The backdrop: The NAIC is a Kansas City, Missouri-based group for state insurance regulators. It cannot set state insurance rules directly, but many states start with NAIC models when creating their insurance laws, regulations and procedures.
Prior authorization programs are efforts by insurance companies, administrators of employers' self-insured health plans and other payers to evaluate proposals for medical care before the care is provided.
Health insurers say prior authorization programs help them confirm that the care recommended is safe, medically necessary, covered by the plan and worth the cost.
Physicians complain that they end up talking to reviewers who are not qualified to review the proposed care.
About 23% of physicians surveyed say they have seen prior authorization-related treatment delays and treatment recommendation denials lead to patient hospitalizations, according to the AMA.
Physicians have been furious about reports that some health insurers may be using artificial intelligence systems to reject prior authorization requests for some types of procedures with little or no live-human oversight.
Dr. Mehmet Oz, President Donald Trump's pick to be the next administrator of the Centers for Medicare and Medicaid Services, said during a Senate Finance Committee nomination hearing last week that one problem is that each plan puts about 3,000 different procedures through prior authorization reviews, and each plan has a different set of procedures subject to prior authorization reviews.
Related: Dr. Oz addresses concerns, including prior authorizations, at CMS confirmation hearing
He proposed having each plan focus on a standard set of about 1,000 procedures.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
