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A team at the National Association of Insurance Commissioners is trying to come up with a way to update the state rules governing health plans' prior authorization procedures.
Health insurers say they need some way to control torrents of high-cost claims.
Elevance, for example, contends that unscrupulous providers and provider representatives are using the No Surprises Act arbitration process for out-of-network claims to send insurers waves of sky-high bills.
Physicians argue that care reviewers without the training or experience to understand the requests for care are wasting their time with endless phone and Zoom meetings over procedures, devices and prescriptions that are clearly needed.
The Regulatory Framework Task Force, part of the Health Insurance and Managed Care Committee, has drafted a prior authorization framework paper, for state insurance regulators, on its section of the NAIC's website.
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The paper starts with basic matters, such as a definition of prior authorization and a description of common prior authorization procedures.
The drafters go on to summarize the providers' perspective, the insurers' perspective and the consumers' perspective.
The drafters have not included a section on employers' perspective. They do note that, under the terms of a model bill developed by the American Medical Association, a "utilization review entity" could be any individual or entity that performs prior authorization reviews. The utilization review entity might work for an employer with a self-insured health plan as well as for a health insurer, according to the drafting team's summary of the AMA model bill.
The bill includes a discussion of responses states have adopted or are considering.
Some of the responses include "gold carding," or strategies for helping some providers get exemptions from routine prior authorization review processes; efforts to require that a plan's prior authorization stay in effect for at least one year or for a patient's approved course of treatment; and efforts to limit how long health insurers and health plans have to respond to prior authorization requests.
The Regulatory Framework Task Force included a draft of the paper and a discussion of it in a document packet prepared for the NAIC's summer meeting in Minneapolis.
The NAIC is a group for state insurance regulators. It normally does not set states' insurance rules directly. But state regulators and state lawmakers often start with NAIC model laws, model regulations, handbooks and other NAIC model documents when developing their rules.
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