Ohio Bill Demands Speedier Decisions From Insurers

Dec. 20--COLUMBUS -- Arguing that the current system can leave ill patients in medical limbo, the Ohio Senate has unanimously approved a bill to require health insurers to make prompt decisions when preauthorizing care and then stick to those decisions.

Senate Bill 129, now in the House, was largely triggered by complaints from doctors, hospitals, and other medical service providers.

"More and more insurance companies are requiring doctors and hospitals to get approval before a medical procedure can be performed or medication prescribed," said Tim Maglione, lobbyist for the Ohio State Medical Association.

"Lots of times, the process lacks transparency, and the process is incumbent with delays," Mr. Maglione said. "Also, sometimes the insurance company comes back and says it's changed its mind after we've already provided the service."

The bill would require insurers to make preauthorization decisions within one business day in urgent cases and within five days otherwise, beginning in 2018. In most cases, the insurers would have to stand by that decision for 60 days.

The bill, sponsored by Sens. Randy Gardner (R., Bowling Green) and Capri Cafaro (D., Hubbard), raised concerns from health insurance companies. It also faced resistance, at least initially, from the business community, which feared that a valuable tool used by insurers to keep employers' costs down was about to be severely weakened.

They were not as confident as Mr. Gardner that any cost increases from the reform would be minimal.

"We were pretty convinced it would contribute to increased costs," said Keith Lake, lobbyist for the Ohio Chamber of Commerce. "But those issues have largely been resolved, so we don't make the case that there's going to be a significant increase."

One reason for that is the elimination of a provision that would have deemed a request for preauthorization of a medical service, medication, or device to be automatically approved if the insurance company missed those deadlines.

The bill would allow insurers to still deny coverage for a previously approved service if it later discovers the patient wasn't eligible for coverage in the first place, such as when an employer switches insurance companies before a claim was made with the old one.

Health insurers dropped their outright opposition to the final version that won unanimous approval in the Senate, but they continue to worry about the bill's effects.

"It is important to recognize that no other state has passed a bill that is as comprehensive as Senate Bill 129 is relative to prior authorization changes," said Miranda C. Motter, president and CEO of Ohio Association of Health Plans.

"And thus we don't have a single state to look at to determine how such provisions have impacted patient care, provider operations, and health-care costs," she said. "To that end, it becomes very important to examine and understand how all of the bill's provisions interact."

Ms. Motter said turnaround times for preauthorization in the bill are inconsistent with national best practices. She also said she's concerned that forcing faster decisions might lead to more denials.

The sponsors of the bill and parties on both sides negotiated for months.

"I think we will have faster, better communication between health insurance companies and medical providers," Mr. Gardner said. "It will be a significant improvement. There will be a more cost-effective, efficient, and transparent prior authorization process, and that's positive for everyone involved -- doctors, hospitals, patients, and health insurance companies.

"There will be the expectation that, once a medication or service is deemed medically necessary, they can move forward with confidence that what they do will continue to be accepted by their health insurance."

The bill would also allow for the preauthorization of a drug for up to a year for chronic conditions and is designed to make it easier for patients, their doctors, or other health-care providers to get preauthorization approval through insurers' websites, rather than relying on fax machines, beginning in 2017.

The bill would require insurers to fully explain to providers the requirements to qualify for preapproval.

Mr. Gardner said he's unsure how the House will react to the bill.

"There was definitely some give and take through the legislative process," he said. "I said right from the beginning that Ohioans have more choices for health insurance than many other states. We did not want a bill that would disrupt Ohio's competitive health insurance market."

Contact Jim Provance at: jprovance@theblade.com or 614-221-0496.

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