RALEIGH — The North Carolina Medical Society is thrilled to announce that it has successfully introduced legislation seeking to reform the overused and burdensome prior authorization process!
On Monday, April 17, 2023, HB 649, an Act to Ensure Timely and Clinically Sound Utilization Reviews and that Medical Decisions are Made by Health Care Providers, was introduced in the NC House of Representatives.
The bill is the direct result of NCMS member engagement. After hearing increased frustration with patient care delays and increased administrative burden associated with many of the largest commercial payors in the state, the NCMS Payor Relations Task Force (Task Force) was formed to hear input from members in a wide range of practice areas, The goal was to identify shared concerns and recommend a framework for proposed solutions. Prior authorization quickly rose as one of the top concerns.
HB 649 seeks to incorporate many of the recommendations made by the Task Force to address prior authorization reform.
If passed, the improved requirements would include the following and more:
- Insurers would be required to talk with a clinician before refusing to pay for prescribed medical care, if medical necessity is being questioned.
- Time limits would be set for reviews based on medical care level and timeframes would be provided to insurers for decision making.
- Physicians issuing approvals and denials must be licensed in North Carolina, actively practicing, and have experience in that specialty or patient treatment.
- Continuity of care requirements, previous prior authorizations must be honored for a time, ensuring coverage for related services.
The NCMS is especially grateful for the support of the bill’s sponsors: NCMS Member Representative Kristin Baker, MD, NCMS Member Representative Tim Reeder, MD, Representative Larry Potts, and Representative Wayne Sasser. Please join us in extending our appreciation to these patient champions!
I have worked in the academic setting and private practice in North Carolina. Over the past 4 years, the burden of prior authorization has led to numerous delays in care and created a financial burden in both practice systems – we have had to hire additional nursing staff to solely deal with prior authorizations, each of which can sometimes take hours at a time to complete even for FDA approved indications. We are not paid for the time spent completing prior authorizations. Pro publica has recently written excellent articles exposing the ethically dubious methods used by insurance companies including mass denials and using non expert physicians or even non physicians in “peer to peer” reviews that deny care recommended by international/national experts in the subject matter.
Too little and ineffective to change anything. It’s like saying we should be nice to the bear before it eats us. Requirevthe insurers pay us for our time. They pay reviewers for theirs. Make the decisions subject to disciplinary action by the NCMB and medical malpractice laws. Require they track and report any harm done by their pa process. Enough being passive to corporate greed and destroyers of the spirits of physicians everywhere. Time to do something that gets results.