Last Updated: Jan 9, 2023
The Pennsylvania Medical Society applauds the Pennsylvania Department of Insurance statement on their findings from a market conduct examination on the Capital Blue Cross practices and procedures, revealing blatant violations and resulting in restitutions for patients across the Commonwealth.
PAMED continues to be a strong patient advocate for insurance reform, including prior authorization, that results in increased transparency with health insurers for medication and treatment approvals. The organization aims to return physicians and patients as decision makers on critical health care decisions without the authority from health insurance executives.
In the PA Department of Insurance statement, the examination includes:
The Capital Blue Cross examination, which covers the period from January 1, 2017, to March 31, 2018, identified concerns with claims processing, including claims being denied for lack of prior authorization when prior authorization had already been obtained, and a coordination of benefits issue that has since been updated.
At the end of 2022, PAMED joined the provider and patient community in celebrating an advocacy victory in the signing of Act 146, prior authorization reform. Act 146 is a first step to ensure increased transparency with medical insurers by providing standardized parameters that govern the relationships between patients, providers, and health insurers. Most importantly, the passage of Act 146 acknowledges that the previous prior authorization was intrinsically flawed.
President F. Wilson Jackson III, MD said, “PAMED has been a long-standing advocate for prior authorization reform and will continue to encourage patients and the health care community to support future patient protection legislation when warranted. On behalf of our patients, we encourage the Insurance Department to continue to critically evaluate health insurer practices so that all Pennsylvanians receive the care they need, and patients and providers are promptly reimbursed as necessary.”
PAMED will continue to advocate for good patient care that is not delayed or prohibited by insurers, leaving the best course of treatment of patients to the health care providers.
Pennsylvania Medical Society
About the Pennsylvania Medical Society
PAMED is a physician-led, member-driven organization representing all physicians and medical students throughout the state. We advocate for physicians and their patients, educate physicians through continuing medical education, and provide expert resources and guidance to help physicians and their organizations navigate challenges in today’s ever-evolving health care system. For more information, visit www.pamedsoc.org