• Measure would put controls in place for prior authorization

By David Velazquez
Casper Star-Tribune
Via- Wyoming News Exchange

CASPER — Legislation that would set controls in place for how health insurance companies approve and deny medical care is one step closer to fruition following introduction and approval from a committee. The Wyoming House on Monday Introduced House Bill 14, which would set regulations for health insurance prior authorization. 

The Labor, Health & Social Services Committee, which has worked with medical groups and insurance companies since mid last year to create the bill, unanimously approved the bill with changes on Wednesday morning. 

Prior authorization is a process health insurance companies use to determine which treatments and medications they will cover and pay for under a patient’s plan. Wyoming is the only state in the country without laws that govern prior authorization. 

Prior authorization has been heavily criticized by doctors and health providers as time and resource consuming while patients wait for care. 

The committee approved four pages of amendments ranging from word changes to changing a measure that would have required health insurance companies to respond to urgent care requests within 24 hours. 

Features kept in the bill include eliminating the need for prior authorization for medication to treat opioid use disorder, guaranteeing access to previously approved medication and treatment for at least 90 days after they switch health insurance plans and patients can access rehabilitative services — such as physical or occupational therapy — without needing prior authorization. 

Added to the bill was a provision that prohibits health insurance companies from requiring a patient to repeat step therapy if they have previously failed it. Step therapy is a process where health insurance companies require patients to take one or more, usually less expensive, medication before “stepping” up to another medication. 

The first draft approved by the Legislature would have required health insurance companies to give doctors an explanation of their treatment plans before their requests are denied. 

New changes to the bill allow health insurance companies to hand out adverse decisions to health care providers, and providers can then request consultation over the decision with a health insurance employee with decision making authority. The health insurance company will have five business days to schedule the consultation. 

Additionally, a change was made to the delay in response time to prior authorization requests. 

The previous version of the bill required health insurance companies to respond within 24 hours of an urgent care request and five business days for all other services. The amendment would give health insurance 72 hours to respond to urgent care requests and in compromise health insurance will now have five calendar days for all other services. 

“In Wyoming we have small companies,” Executive Director of the Wyoming Medical Society Sheila Bush said at a committee meeting Wednesday Morning. “They very earnestly presented to us that (24 hours) is not a possibility, it’s just not a feasible timeline for them.” 

Bush emphasized at the committee meeting that urgent care is different from emergency care, which does not require prior authorization. 

A minor change was made to a “gold card” system, which would allow doctors to skip prior authorization for certain procedures and treatments. 

Previous wording allowed doctors who have requests approved 80% of the time eligibility. New wording bumps the threshold up to 90% but doctors with an 80% approval rate would still qualify for a “gold card” due to how eligibility is calculated. 

Pharmaceuticals were removed from eligibility from the “gold card.” 

Other changes to the bill were small, focusing on definitions and changes in wording. 

The bill will be sent back to the House where it will be voted on twice before being sent to the Senate. The Senate will vote on the bill and make changes through a committee if needed. The bill will be sent to Gov. Mark Gordon if the House and Senate both approve the same version of the bill.