Health insurers prior authorization targeted by lawmakers in 29 states – USA TODAY

February 13, 2024

Christopher Marks noticed an immediate improvement in his symptoms when his doctor prescribed Munjaro, a type 2 diabetes drug, last year. A 40-year-old truck driver from Kansas City, Missouri, said his average blood sugar levels have dropped significantly and he is taking less insulin than before to keep his blood sugar levels within target range.

But if his doctor followed his instructions; Typical prescription pattern And at wholesale price Over $1,000 Marks’ health insurance company refused to pay the cost.

Marks had Cigna insurance purchased on the federal health insurance market. healthcare.gov. After a month and a half and two appeals, Cigna agreed to cover the higher doses. A few months later, when it came time to increase his dose again, he said he was denied it again. By November, we decided it wasn’t worth sparring with Cigna anymore because the insurance company was pulling out. missouri market At the beginning of this year. He decided to continue on the lower dose until his new insurance covered him.

“It’s very frustrating. People shouldn’t have to think, ‘It’s not worth fighting to get treatment,'” Marks says.

The process Marks encountered is called “preauthorization,” or sometimes “preauthorization,” and claims insurers use it to control costs and protect patients from unnecessary or ineffective care. are doing. But the move has drawn backlash not only from patients like Marks, but also from medical professionals and groups representing hospitals, who say it can only be done with prior permission. interfere with treatmentmedical causes provider burnoutand Increased management costs.

Biden administration takes office in January announced new rules to streamline the process for patients with certain health plans after attempts in Congress stalled. bill passed by the House of Representatives However, states are considering preclearance legislation that goes even further. Last year, lawmakers in 29 states and Washington, D.C., considered about 90 bills that would limit preclearance requirements. According to the American Medical Associationwon a notable victory in new jersey and Washington DC The medical association expects more bills to be introduced this year, many of which include provisions such as: model legislation The group drafted.

In 2018, health insurance companies signed the following agreements: consensus statement We worked with a variety of healthcare facilities and provider groups to highlight a wide range of areas for improving the prior authorization process. However, he said the lack of progress since then shows the need for legislative action. jack resneck jr.is a past president and current board member of the AMA.

“They haven’t delivered on their promises,” Resneck said.

Resneck, a California dermatologist, highlighted the outstanding bill. Indiana, Massachusetts, north carolina, oklahomaand wyoming This includes several AMA-supported policies, including reduced response times, public reporting requirements for insurers’ preauthorization decisions, and a program to reduce application volume, also known as “gold carding.” The bill has been introduced by both Democratic and Republican lawmakers, and some are bipartisan. like colorado.

In Missouri, Law introduced by Republican state legislators. Melanie Stinnett aims to establish one of the gold card programs for treatment and prescription. Stinnett said that before joining Congress in 2023, she was regularly frustrated by prior authorization hurdles in her work as a speech therapist.

“The stories are all similar. It’s a big battle to get something done on the insurance side to get it approved,” Stinnett said. “Then even after all the battles, you can feel like it might not have been worth it because some people change their insurance in the new year.”

His bill would review health care providers’ prior authorization requests during a six-month evaluation period. After this period, providers whose requests are at least 90% approved are exempt from the obligation to submit requests for the next six months. The exemption also applies to facilities that meet that criteria. And they would still have to meet the criteria to maintain the “luxury” of exemption, she said.

Five states have passed some form of gold card program: Louisiana, Michigan, Texas, Vermont, and West Virginia. AMA tracks active gold card bills in 13 states, including Missouri.

a 2022 survey Of the 26 health insurance plans surveyed by industry group AHIP, just over half were found to be using medical insurance plans. gold card program They used it for medical services, and about one-fifth used it for prescriptions. They gave mixed reviews, with 23% saying patient safety improved or remained the same and 20% saying the practice increased costs without improving quality.

new federal government Pre-authorization rules The decision finalized by the Centers for Medicare and Medicaid Services stops short of a gold card and does not address pre-authorization for prescription drugs like Marks’ Munjaro prescription. Starting in 2026, new rules will establish response time frames and public reporting requirements for some insurers participating in federal programs such as Medicare Advantage and the Health Insurance Marketplace, and will eventually introduce electronic processes. will be required. According to the 2022 Insurance Survey, manual submissions accounted for 39% of preauthorization requests for prescriptions and 60% of preauthorization requests for medical services.

In Missouri, state and national organizations representing doctors, nurses, social workers, hospitals and others support Stinnett’s bill. Opposition to the plan comes primarily from pharmacy benefit managers and the insurance industry, including the company Marks handled the preauthorization process for last year.Cigna Healthcare testimony submitted The company said its experience showed the Gold Card policy “increased inadequate care and costs.”

of St. Louis Regional Business Health CoalitionGroups representing dozens of employers who offer employee health insurance also oppose the bill. Members of the coalition include financial services company Edward Jones, coal company Peabody Energy and airline giant Boeing, as well as several public school districts and the St. Louis city and county government.

Louise Probst, the coalition’s executive director, said the pre-authorization process is problematic, but the coalition would prefer a solution from insurance companies and health care providers rather than new state laws.

“The reason I don’t like to see things freeze is because you lose flexibility and nuance that could be helpful to patients,” Probst says.

On the other side of the state, Marks bought this year’s insurance on the federal market from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed a higher dose of Munjaro, which Cigna refused to cover. About a week later, Marks said, his new insurance approved the higher dose “without any fuss.”

Cigna spokesman Justin Sessions said the company uses prior approvals for popular drugs such as Munjaro to ensure patients receive the right drug and dose.

“While we strive to ensure that approvals are made quickly and accurately, in Mr Marks’ case we fell short and we deeply regret the stress and frustration this has caused,” she said. Stated. “We are reviewing this matter and identifying opportunities for improvement to prevent this from happening in the future.”