NC House Bill Targets Insurance Company Prior Authorization Practices
Raleigh, NC – A bill introduced in the North Carolina House of Representatives seeks to reform the process that insurance companies use for prior authorization, a practice that requires doctors to get approval from the insurance company before prescribing certain medications or procedures. The legislation addresses long-standing criticisms about the process.
Linsi Franklin of Wake County describes her struggles getting her son’s medicine approved at a news conference on insurance company prior authorization. (Photo: Lynn Bonner)
Linsi Franklin of Wake County described her personal experience with prior authorization as she spoke at a news conference. Franklin recounted the challenges she faced in getting her son’s medication approved. “For weeks, I would spend hours on the phone daily with the insurance company and the pharmacy, trying to push the prior authorization through,” she said. “I am fighting for prior authorization reform in North Carolina because my son, other 10-year-olds, and other families in North Carolina shouldn’t have to.”
House Bill co-sponsors include Representatives Timothy Reeder (R-Pitt) and Grant Campbell (R-Cabarrus), both medical doctors. The North Carolina Medical Society and the North Carolina Healthcare Association are supporting the bill. The Healthcare Association represents hospitals, and the Medical Society represents doctors.
“This bill is going to allow physicians to be the ones to make medical decisions for their patients,” Campbell said. “We’re starting to step between the line of people that are trying to elbow their way in between doctors and their patients.”
The bill aims to address common complaints about prior authorization, namely that decisions take too long and that the doctors insurance companies hire to review cases aren’t specialists in the relevant areas. The new bill would set time limits for insurance companies to notify doctors if the medical necessity of a service is questioned. Insurance companies would also be required to make a public list of services that require review. Patients and their doctors would need to be notified whether a non-emergency service is approved within 48 hours of the insurance company receiving all information about it.
Campbell spoke about a patient with a “complex ovarian mass” suspected to be malignant whose surgery was delayed six weeks because of insurance denials, exemplifying the real-world impact of these delays. “The parade of people that are trying to interfere with the relationship with the patient and their physician has got to stop,” he emphasized.
Peter Daniel, executive director of the NC Association of Health Plans, said in an interview that he had not seen the bill prior to publication and had not yet examined all the details. “On behalf of the association, I can say that we support a balanced and reasonable approach to reforming the prior authorization process, one that ensures patient safety, maintains health care efficacy, and reduces administrative burdens for providers,” he said.
Breast Cancer Screening Bill Advances
The legislature is also considering other healthcare legislation this year. The House Health Committee recently approved a bill to make advanced imaging, which can better detect breast cancer, more accessible. House Bill 297 is designed to assist those at increased risk of breast cancer, those who have survived the disease, and those with breast abnormalities, according to Representative Mary Belk (D-Mecklenburg).
Insurance copays can vary widely for the more advanced cancer detection methods, she noted. Under the bill, insurers would have to apply the same cost-sharing requirements regardless of the type of breast cancer detection method used, and pay the in-network rate for patients who see out-of-network providers. Belk noted that the House has approved the bill in three previous sessions, but it has not yet passed the Senate. Sponsors of the bill made some changes this year to improve its chances.
