“Filling out these crazy forms” – Pa. law would regulate insurance pre-authorizations

This Week in Pennsylvania

(AP Photo/David Goldman, File)

HARRISBURG, Pa. (WHTM) — A solution to a long-running problem? Or a cure that’s worse than the disease? Depends on who you ask.

Insurance pre-authorization — or “utilization management,” as the process is known nowadays — isn’t new. But some doctors say they’ve become increasingly burdensome in the past few years.

“A spine surgeon colleague of mine had a patient who was having neurologic problems and urinary problems, and they needed surgery, but they were told to perform physical therapy first,” said Dr. Matthew Kelly of the Orthopedic Institute of Pennsylvania in Camp Hill. “Well, of course, that delayed the surgery, but then they needed urgent, emergent surgery.”

Kelly said his practice has 18 office workers managing authorization paperwork, supporting 16 surgeons. He said problems aren’t isolated.

“The day before a surgery, I’m in the office with a busy day, and all of a sudden we get a notice that the insurance company has canceled the case,” Kelly said.

Dr. Suzette Song, of OSS Health in York, agreed.

“It used to just be a little bit of paperwork sometimes on the complicated cases,” Song said. “Our secretaries could take care of it.”

But now? “Every practice has, like, an entire department devoted to prior authorizations,” she said. “Filling out these crazy forms, trying to make sure you’re putting the stuff in the right boxes.”

The solution? Doctors hope it’s legislation sponsored by State Sen. Kristin Phillips-Hill (R-York) and State Rep. Steven Mentzer (R-Lancaster), which would require a “standard prior authorization form that can be electronically submitted by all health care providers and accepted by all health insurers.”

“We’re going to eliminate a ‘fail first’ approach, which is known as ‘step therapy,'” Phillips-Hill said, “some of the most conservative and liberal members of the Senate” have joined her as co-sponsors.

Sam Marshall, president of the Insurance Federation of Pennsylvania, which represents some of the largest health insurance companies in the state, agrees that the pre-authorization process was “inconsistent, inefficient, cumbersome, bureaucratic and biased” — in the past. But he said that has evolved into a system that’s “more efficient, more transparent and more technologically friendly” while still controlling costs, which he said is in the interest of the public.

No insurance company wants, in any way shape or form, utilization management that would somehow undermine the wellbeing of our patients, our policyholders,” Marshall said. “What we do want is good medical care at a price our policyholders can afford, and that includes utilization management.”

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