Administrative Simplification Sen. Robert Mills - SB 112 - Gold Card for Prior Authorization White Coat Wednesday WHY SHOULD I SUPPORT SB 112? Creates an exemp � on for qualifying healthcare providers and facili � es that have obtained a prior authoriza � on for 80% of all requests for a par � cular service to a par � cular health insurance issuer within the prior 12 month period AND requires a health insurance issuer to � mely pay for a prior authorized service except under limited circumstances. U � liza � on review, such as prior authoriza � on is a managed care technique that allows health insurance companies, to manage the cost of health care bene ts by assessing the appropriateness of a service, before it is provided. Unnecessary administra � ve burdens created by insurance companies con � nue to increase as more and more services are being subjected to prior authoriza � on requirements. U � liza � on review en �� es’ prior authoriza � on criteria and requirements vary extensively. Lack of standardiza � on creates tremendous administra � ve burden. A u � liza � on review en � ty should not revoke, limit or condi � on coverage for a prior authorized service that has already been provided. This unnecessary burden for high performing healthcare providers with a clear history of appropriate resource u � liza � on and compliance with clinical criteria is unjus � ed. Health Plans should restrict u � liza � on management programs to outlier providers. U � liza � on management programs such as prior authoriza � on, create signi cant barriers for pa � ents by delaying the start and con � nua � on of necessary treatment and may nega � vely impact pa � ent health outcomes. Unnecessary and inappropriate denials or delays in u � liza � on review may impact a carefully planned course of treatment between the pa � ent and the physician. These programs should be based on accurate and up ‐ to ‐ date clinical criteria, not just cost. Health Plans may deny payment for previously approved services based on criteria outside of the prior authoriza � on review process. This unexpected denial creates hardships for pa � ents and providers. Lengthy processing � me can delay necessary treatment, poten � ally crea � ng pain and medical complica � ons for pa � ents.
Manual Ɵ me consuming administra Ɵ ve burdens divert valuable resources away from direct pa Ɵ ent care.
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PhysicianLedMed | physiciancoali Ɵ on.org
20 J LA MED SOC | VOL 174 | SUMMER 2022
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