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Legislators, doctors want rules on prior authorization

By Aedan Hannon
Casper Star-Tribune
Via- Wyoming News Exchange

CASPER — For the first time, Wyoming lawmakers are looking to put in place rules that guide how health insurance companies can approve and deny medical care. 

However, the second interim meeting of the Joint Labor, Health and Social Services Committee Thursday in Evanston revealed the gap that exists between insurance companies and health care providers and lawmakers as the legislative panel weighed the first draft of prior authorization regulations proposed by the committee’s working group. 

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

Led by Sen. Dan Dockstader, R-Afton, and Rep. Sarah Penn, R-Lander, the committee’s working group met in May with medical groups and insurance companies to begin to hash out prior authorization rules that would be acceptable to both groups ahead of next year’s legislative session. 

Doctors, other health care providers and medical facilities have complained that prior authorization is an approval system gone astray, increasingly consuming their time and resources while delaying and blocking care for patients. 

Insurance companies have argued that they are serving as financial stewards for their members while using the process to help control the quality of health care. 

During their April meeting in Casper, lawmakers on the committee unanimously voted to draft a bill that would rein in the power of health insurance companies in Wyoming. 

The resulting 32-page draft bill met resistance from insurance companies during Thursday’s meeting, with the companies pointing to several issues that they said need to be addressed. They urged the panel to allow the companies and medical groups to continue to work together with lawmakers to refine the law.

“We all worked very hard to come to some consensus on things we could come to consensus on and there were some things we couldn’t and frankly we ran out of time,” said Bruce Spencer, an attorney who represents Mountain Health CO-OP, which covers roughly 18,000 Wyomingites. 

Among the concerns representatives for Mountain Health CO-OP and Blue Cross Blue Shield of Wyoming raised were data reporting requirements that would force insurance companies to share information about when they deny medical services. The draft law would also require companies to consult with doctors if they were considering denying care because it was not a “medical necessity,” an extra step that the representatives said would lengthen treatment approval times. 

As the bill is currently written, insurance companies would have five days to approve or deny non-urgent treatment requests and 72 hours for urgent requests. 

“It will lead to an increase in holding the line of just denying things because you’ve got to hit those timelines,” said Ken Schaecher, a physician, medical director and administrator who works with the University of Utah and Mountain Health CO-OP. 

The companies also objected to a “gold card” system that would allow doctors to skip prior authorization requests if their treatment plans were approved by an insurance company at least 80% of the time. 

“We don’t use prior authorizations as mechanisms not to pay for care,” said Heather Roe Day, a lobbyist for Blue Cross Blue Shield of Wyoming. 

She added that prior authorization approvals ensure that insurance companies use limited resources effectively, patients receive evidence-based and necessary treatment, and health care providers are paid. 

The insurance companies found some sympathy. 

Cheyenne Republican Rep. Dan Zwonitzer, the co-chair committee, said the bill wasn’t yet ready for the 2024 legislative session, acknowledging that lawmakers heard the companies’ concerns. 

But others expressed skepticism, aligning themselves with the medical groups who spoke. 

“We still have a situation where we’re not providing enough follow-up care without all the confusion of waiting and delays,” Dockstader said. “I would hope you’d have an understanding that we also want to protect the money – it’s other people’s money and we want to protect that – but we also want to get to a point where people are not waiting for good health care,” he added. 

Sheila Bush, the executive director of the Wyoming Medical Society, and Eric Boley, the president of the Wyoming Hospital Association, encouraged lawmakers to avoid the “rabbit holes” of the insurance companies. 

Both supported the bill as it was written, saying they thought it only needed minor changes.

 “It feels like much of the conversation this morning has been the resistance to reform prior authorization because insurance companies have aggressively moved into the role of policing safe medical practice,” Bush said. “That isn’t an appropriate mechanism or utilization of insurance. That’s not their role.” 

Boley refuted the claim that prior authorization serves to protect patients and medical providers. 

“We’ve heard from the insurance companies that this isn’t done for cost containment,” he said. “That’s an absolute fallacy.” 

During the committee’s first April hearing, testimony from doctors, hospitals and medical groups swayed the lawmakers as they spoke of the burden of prior authorization. 

Dr. Kevin Helling, a Casper-based general surgeon, expressed concern about what he said were essentially blanket denials from insurance companies that were hurting patients and doctors. 

“My expectation is that they’re going to say, ‘No,’” he testified. “I’m not even sure that they read them.” 

Lawmakers once again gravitated toward the medical groups Thursday. 

When asked if they thought insurance companies should be required to have a shorter turnaround time for approvals, the majority voted in favor of updating the bill so that companies have 24-hour deadlines for urgent treatment and 48-hour deadlines for non-urgent care. 

Dockstader and Penn will once again lead a working group to find more agreement between the insurance companies and medical groups ahead of the health committee’s next meeting in Saratoga in September. 

But for now, the lawmakers have the approval of at least one side. 

“As far as I’m concerned, we’re ready to roll,” Boley said, a statement to which Sen. Anthony Bouchard, R-Cheyenne, replied: “I agree with you.”

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