Source: Ohio State Medical Association
Senate Bill 129, health the prior authorization (PA) reform bill strongly supported by the Ohio Academy of Family Physicians and the Ohio State Medical Association (OSMA), has cleared the Ohio Senate. The bill is sponsored by State Senators Randy Gardner (R-Bowling Green, OH) and Capri Cafaro (D-Hubbard, OH).
- Requires insurers to have a web-based system to receive PA requests
- Requires insurers to disclose all PA rules to providers
- Requires that health plan enrollees must receive basic information about which drugs and services will require PA
- Extends originally-proposed turnaround times for PA decisions for non-emergency/non-urgent situations
- Allows insurers the opportunity for “retrospective review” for unauthorized procedures that were performed during an authorized procedure, with some limitations
- Includes a provision related to retrospective denial, which would protect coverage and medical necessity if a procedure was performed within 60 days of receiving authorization.
In proponent testimony, OAFP President Tom Houston, MD, stated, “An essential part of the practice of medicine is to have weighed various considerations before prescribing a medication or an intervention. PA forms have evolved away from just cost considerations into a review of treatment practices in general. As a result, these PA forms sometimes request the attachment of pertinent medical history and include questions regarding diagnoses, risk and benefit, alternatives, effectiveness, stability of symptoms, side effects, and other considerations. Not only do physician practices face increased numbers of PA requests, the complexity of these requests creates a huge administrative burden for the physician and the physician’s practice team. PAs cause immense frustration for patients and physicians. And they can delay much needed treatment and in some cases result in inappropriate care for our patients.”
Dr. Houston continued, “This legislation seeks to even the playing field between insurance companies and physicians with regard to the PA process. Managed care companies will undoubtedly fight this bill as they consider these matters to be a subject for contract negotiation, but in reality, physicians individually do not have much ability to negotiate terms that are favorable to their patients or to them. Physicians often feel powerless when advocating with payers on behalf of their patients.”
Senate Bill 129 will now be considered by the Ohio House of Representatives.