PAMED praises Governor; Raises Concern About Prior Authorization

The following is a statement from Theodore Christopher, MD, president of the Pennsylvania Medical Society. Dr. Christopher is also professor and chairman of the Department of Emergency Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia. He reacts to Governor Wolf waiving the prior authorization process for Medicaid patients being treated for opioid use disorder.

(Harrisburg, Pa. – 3/5/18) Recently, Governor Tom Wolf announced plans to remove treatment barriers for people receiving medication-assisted treatment for opioid use disorder. Specifically, his administration will be waiving prior authorization requirements for those who have Medicaid and need evidence-based opioid use disorder treatment.

ChristopherblogIt’s well known that medication-assisted treatment (MATs) when combined with counseling and behavioral therapies can help a patient work to avoid relapse and improve the odds of recovery.

The Pennsylvania Medical Society applauds Governor Wolf for recognizing negative consequences prior authorization can have on this population of patients.

As physicians can attest, the current prior authorization process can delay care when patients need it the most. It’s problematic not only for those battling opioid use disorder, but also for many other conditions.

For example, the Pennsylvania Medical Society is aware of patients who suffered delays from their insurance coverage for care recommended by their physician. Only after hours on the phone by both patients and their physicians were denials reversed.  In some cases, insurers “dug in” and never approved the recommended treatment.

There’s the story of Joe Stanziano of Montgomery County (Pa.), who was taking pain medication to recover from multiple back surgeries. Things were progressing well enough for Stanziano to begin taking a smaller dose of the medication – a process known as tapering that could eventually allow him to wean off the medication altogether.

The problem is, Stanziano's insurance company denied payment of the lower dosage that his neurologist prescribed. Hours turned into days and Stanziano continued to wait for his insurance company's approval. When his medicine ran out, withdrawal symptoms began.

And let’s not forget Middletown, Pa., teenager Zachary Souders, who was caught in the middle of a confusing and convoluted prior authorization process that caused him to unnecessarily suffer months of pain due to juvenile idiopathic arthritis. It took his family and his physician months to convince his insurer to approve coverage of a treatment that ultimately brought relief.

Patients deserve timely and appropriate care when their physicians recommend it. Unfortunately, that doesn’t always happen.

Legislation that could help solve this problem is currently under consideration by the House Insurance Committee.  Pennsylvania House Bill 1293 was introduced in May 2017 by Rep. Marguerite Quinn (R-Bucks) seeks to streamline the prior authorization process, improve transparency and gives health insurers a deadline to make a decision.

Prior authorization concerns continue to grow suggesting that the time has come for a public hearing on House Bill 1293.It’s important that this bill moves to give other patients a fighting chance to receive timely care. They don’t need to suffer like Joe Stanziano and Zachary Souders.

Patients who find themselves battling health insurers over approval of care need to do two things.

First, they should make an official complaint to the Pennsylvania Department of Insurance. That can be done through a website set up by the insurance department at http://www.insurance.pa.gov/Consumers/File%20a%20Complaint/Pages/default.aspx or by calling 1-877-881-6388.

And, second, they should contact their State Representative and urge them to support House Bill 1293.

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The Pennsylvania Medical Society was founded in 1848. To learn more about PAMED, visit its web site at www.pamedsoc.org or follow on Twitter @PAMEDSociety. 

2 comments

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  1. Jeff Wirick | Mar 12, 2018

    Thank you Dr. Murdoch for your comments. They will be passed along to our Government Affairs staff. We hope you continue to help us seek passage of HB 1293, which aims to improve the prior auth process. Below are some highlights of the bill - and you can find more info on our website at www.pamedsoc.org/PriorAuth ...

    Requires insurers to post on its website a current list of services and supplies in need of prior authorization and the written clinical criteria

    Restrictions an insurer places on prior authorization services must be based on the medical necessity or appropriateness of those services and on written clinical criteria

    Appeals must be reviewed by a physician who is board certified in the same specialty and in active clinical practice

    Requests for an urgent decision must be answered within one business day; non-urgent PAs must be answered in two business days.

    Any change to a prior authorization requirement or a restriction must be made at least 60 days before the requirement or restriction is implemented

    Health insurers may not retroactively deny coverage for emergency or non-emergency care that had been pre-authorized.

  2. Winslow W. Murdoch | Mar 09, 2018

    Please be aware,

    Prior auth goes far beyond medically assisted treatment for opioid dependancy and abuse disorder. As a primary care doctor, this abomination affects and interferes with every descision. This now  includes many generic, as well as branded medication. Commercial insurance companies in collaboration with the pharmaceutical and Prescription Benefit Management companies, becoming one in the same, thrive on rebates and kickbacks. This very process opaquely stops every aspect of descision making from a primary care perspective. This directly injures the patient doctor relationship in all realms of care. Primaries, who are overwhelmed with the process must readily refer to specialty care to help with the dysfunction. This rapidly escalates the costs of care, and prevents specialists from being available, and focusing on our real patient needs.

     

    We need a doctors PBM. All discounts and manufacturer rebates directly to our patients. Full STOP

     

    sorry, no spell check on this app.

     

    Winslow Murdoch, M.D, Family Doctor

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