Ban on prior authorization expected to trim red tape

Iowa patients will soon no longer need to wonder if their health insurance companies will approve certain care their doctors recommend. Gov. Kim Reynolds recently signed a bill banning prior authorizations for cancer screenings and emergency care.

Some healthcare providers say House File 2635, signed into law May 13, is a way to remove some red tape that can delay needed healthcare and create a heavy burden for providers.

Providers send prior authorization requests to a patient's health insurance company to determine whether or not insurance will cover the recommended care. Requests can include anything from medications to imaging to specialist referrals.

The insurance company will then approve or deny the prior authorization. Denials, however, can be appealed. Some requests are done via online portals, but there's still a large paper and fax component for many prior authorizations. The practice of getting insurance's approval places the burden on the provider and other healthcare staff.

All that paperwork adds up. For Dr. Wendy Woods-Swafford, a pediatric hematologist oncologist and chief medical officer at UnityPoint Health, filling out prior authorizations means spending another three hours on one patient per week. She explained her staff spends the same amount of extra time on each patient.

"It's time consuming but probably more importantly, it impedes patients from being able to actually get the care that they need," Woods-Swafford said. She said most of the time denials are overturned, but the time to get that approval is excessive.

Rep. Austin Harris, R-Moulton, managed House File 2635 through the legislative session. He said prior authorizations are bureaucratic red tape providers have to go through in order to give care and "delays care by several weeks sometimes."

Some insurance companies already have no prior authorization needs for certain services. For instance, Wellmark Blue Cross and Blue Shield said in a statement it's never required requests for emergency services. Many cancer screenings and cancer-related services also don't need authorizations.

"Wellmark Blue Cross and Blue Shield is committed to providing coverage that supports access to safe, effective and affordable healthcare for the people we serve," according to the company.

The Federation of Iowa Insurers said in a statement its members support cancer screening that's "consistent with National Comprehensive Cancer Network guidelines and no prior authorization requirements for emergency care."

The National Cancer Institute said the guidelines are specific to each type of cancer and outlines surgical procedures and drug treatment regimens.

While pushing the bill through the House, Harris said he heard from physicians who said the administrative burden, including prior authorizations, is leading to burnout and causing some providers to leave the medical field altogether. Providers "feel like they're spending more time on a laptop having to fight insurance companies than they are actually spending time with patients," Harris said.

He added he views the law as "a really underestimated recruitment tool" because it allows "providers to actually spend more time bringing care to patients than pushing paperwork."

Harris heard from leaders at the University of Iowa, UnityPoint, and MercyOne who view the new law as a way to entice more physicians to practice in Iowa, especially as the state faces a shortage of medical providers.

Harris also heard feedback on who at the insurance companies should be reviewing the prior authorization requests the bill does not address. Health insurance companies employ health professionals. Sometimes they're former doctors. Those providers, however, do not need to have knowledge of the area of specialty the prior authorization covers. The bill will mandate insurance reviews are done by a healthcare professional in the same or similar specialty as the provider requesting approval.

Woods-Swafford, said she was excited about that detail in the bill, knowing the reviewer has treated what she's working to treat. "They understand what imaging you've already done or what therapies you've already tried," she explained.

"You've already tried the standard of care … and now you're in a kind of gray area where there isn't a standard treatment anymore. I understand how you got here, and I'm going to approve this therapy," she gave as a hypothetical.

With the new law starting Jan. 1, she wants patients to know "that clinical decisions are going to be validated in real time by people, not just an algorithm" and that the "process is going to be more transparent."

"There's going to be more accountability in those denials because it's not just going to be an auto denial and a fax without thinking about the human on the other end," Woods-Swafford said.

The bill also limits the use of artificial intelligence in the review process to the point that insurance companies may not solely use it to determine approval. A human must be involved in the process.

Still, Woods-Swafford said she would like to see the bill go further, perhaps introducing pharmacy reviewers for the drug component. The pharmacy is another route in which insurance companies can deny care in prescribed medications.

She said it would be better for all to remember that through the process of finding efficiency, there's a patient at the other end. While waiting on prior authorizations, delays can take 21 to 28 days, "and that would otherwise be considered unacceptable in the world of medicine for delaying treatment unnecessarily," she said.