Labor committee endorses health insurance regulations despite industry pushback

Wyoming is a step closer to new rules that would reign in how health insurance companies in the state approve and deny medical care.

Lawmakers on the Joint Labor, Health and Social Services Committee agreed unanimously Friday in Saratoga to sponsor legislation that would regulate prior authorization in Wyoming for the first time. They did so despite objections from health insurance companies and industry groups, once again siding with doctors and hospitals as they have done throughout the interim session.

Prior authorization is the process by which health insurance companies determine which treatments and medications they will cover and pay for under a patient's plan. The "Ensuring Transparency in Prior Authorization Act" would have broad implications for how doctors and health insurance companies manage treatment and prescription approvals for patients.

The new regulations would impose time limits, create an automatic approval process for doctors and eliminate the need for approvals for opioid use disorder medications. Health insurance companies would have to respond to prior authorization requests within 24 hours for urgent care and five business days for all other services. Doctors who have their requests approved 80% of the time over a year would be eligible for a "gold card" that would allow them to skip the prior authorization process for certain treatments. Health insurance companies would also have to give doctors the chance to explain their treatment plans before their requests are denied.

While many of the changes would rework the relationship between medical providers and health insurance companies, they would also directly reshape patient care in Wyoming. The rules would guarantee patients access to previously approved treatments and medications for at least 90 days after they switch health insurance plans. Patients would be shielded for a year if their health insurance plan changes their coverage or the approval criteria for their treatment. They could also access physical therapy and other rehabilitative services without needing prior approval.

Health insurance companies in Wyoming would also have report their prior authorization data publicly for the first time under the regulations, including when and why they deny care.

Doctors, hospital administrators and medical groups applauded the new rules Friday during testimony, presenting prior authorization as one of the most pressing challenges health care providers and patients face.

"It will improve the amount of time that my staff have to actually do what we want to be doing and that's taking care of people," said Jeffrey Mincy, the CEO of North Platte Valley Medical Center.

"This is not a challenging decision to decide: Are prior authorizations overly burdensome?" Mincy said. "They indeed are."

While medical providers backed the regulations, health insurance companies and groups like America's Health Insurance Plans, the industry's advocacy and trade organization, raised a series of objections, offering lawmakers a numbers of amendments to address their concerns. They asked lawmakers to strike the gold card program for doctors and the exemption for opioid medications, as well as the requirement that doctors have the chance to talk with health insurance companies before their treatment requests are denied. Representatives for Blue Cross Blue Shield of Wyoming and Mountain Health CO-OP also appealed for longer response times for urgent care requests and shorter timeframes for authorization reviews, among other asks.

They gave a myriad of reasons why they wanted to overhaul the bill, arguing that various provisions would create more bureaucratic hurdles, impacting response times and affecting care for patients while raising costs and premiums. In what has at times been a heated debate, the health insurance companies also pointed to malpractice and the need for oversight of doctors in highlighting the necessity of prior authorization.

"Blue Cross Blue Shield of Wyoming wants to pay for appropriate care and we do not use prior authorizations just to avoid paying claims," said Heather Roe Day, a lobbyist for Blue Cross Blue Shield of Wyoming. "Prior authorizations are important for ensuring members receive safe and effective health care while protecting their health care dollar."

Lawmakers were unconvinced by the arguments. They voted to advance the bill to the 2024 legislative session without weighing or including any of the amendments the health insurance groups had called for.

The decision brings an end, at least for now, to months of wrangling. Prior authorization was one of the Joint Labor, Health and Social Services Committee's interim priorities. Over the panel's three meetings it received significant attention, including a dedicated working group led by Sen. Dan Dockstader, R-Afton, and Rep. Sarah Penn, R-Lander, meant to bridge the differences between doctors and health insurance companies.

While all of those involved suggested prior authorization in Wyoming needs reform, lawmakers have continually sided with the doctors and medical providers advocating for greater regulation of the practice. During Friday's meeting, health care groups again testified that prior authorization was a system run amok.

"Insurance creates and places a ton of burden on providers to jump through hoops to deliver the care that they think is best for patients," said Josh Hannes, the vice president of the Wyoming Hospital Association. "We think that that power dynamic needs to change."

"What is the role of insurance?" he said. "What we would say is that the role of insurance is to simply pay health care bills, full stop."