The scales of Justice are tipping in favor of patient care
Three things to know:
1. State Rep. Jonathan Karlen is sponsoring two bills, according to the report. The first aims to remove prior authorization for most generic drugs, inhalers, and insulin. The second bill would ensure that patients cannot be denied medication when switching payers and awaiting authorization from their new insurer. Additionally, the second bill would only allow a physician with a matching specialty to deny a treatment or procedure.
2. State Rep. Ed Buttrey plans to introduce a bill that would impose a seven-day limit to decide whether to authorize expensive biologic treatments, according to the report. If payers don't meet that deadline, the treatment will be automatically approved. His bill would also eliminate most retroactive denials.
3. State Sen. Vince Ricci told KFF Health News that he is drafting bills that could impose even stricter limits on prior authorization for medications used to treat various conditions.
HELENA, Mont. — When Lou and Lindsay Volpe’s son was diagnosed with a chronic bowel disease at age 11, their health insurer required constant preapproval of drugs and treatments — a process the Volpes say often delayed critical care for their son.
“You subscribe to your insurance policy, you pay into that for years and years and years with the hope that, if you need this service, it will be there for you,” Lou Volpe said. “And finally, when you knock on the door and say, ‘Hey guys, we need some help,’ they just start backpedaling.”
The Volpes, who live in Helena, and their health care providers spent more than 18 months pushing for these approvals from Blue Cross and Blue Shield of Montana — including a four-month wait last year for approval of costly infusions that worked to control their son’s disease where other treatments had failed.
“It just really slowed everything down on his treatment, and I feel like he could have been recovering from this situation a lot sooner,” Lindsay Volpe said.
Now, the Volpes, other patients, and their health care providers are bringing the issue to the 2025 Montana Legislature, saying it’s time Montana joined many other states in limiting how and when insurers can deny drugs or treatments through their preapproval process, known as “prior authorization.”
This month, Democratic and Republican lawmakers introduced or were drafting separate bills restricting health insurers’ ability to require prior authorization for certain treatments and medications. A third lawmaker was preparing other measures as well.
Many of the state’s medical providers are behind the effort, saying prior authorization is denying vital care and needlessly sucking up more and more of their time, which they say could be better spent with patients.
“It has increased incredibly in the last couple of decades, to the point that it’s one of the leading causes of burnout for physicians,” said Lauren Wilson, a Missoula pediatrician and past president of the Montana chapter of the American Academy of Pediatrics. “It’s just delaying patient care for no good reason.”
Montana health insurers, however, insist they are authorizing drugs and treatments that are shown to be needed. If their review power is stripped away, costs will continue to increase due to insurance paying for unnecessary treatments, they said.
Blue Cross and Blue Shield of Montana said it doesn’t comment on individual cases, such as the Volpes’, but said it approves the “vast majority” of prior authorization requests. Blue Cross, which insures or manages health insurance for 384,000 people in Montana, also said it regularly audits its prior authorization procedures and is taking steps to speed up the process.
“Prior authorizations are a way to ensure members receive the right care at the right place at the right time, avoiding unnecessary services and helping providers understand coverage before a service is delivered,” the company said in a statement.
Denial of care through insurers’ prior authorization processes has struck a nerve nationwide as well.
In the wake of the December shooting death of UnitedHealthcare CEO Brian Thompson in New York City, customers of the health insurance giant and other consumers took to social media to denounce the industry for denied claims and puny reimbursements.
And since then, one of the nation’s largest health insurers, The Cigna Group, announced it would spend $150 million this year to reform its prior authorization process and related services for patients and health care providers.
In the past two years, multiple states have passed laws restricting prior authorization, according to the American Medical Association, with New Jersey enacting restrictions over New Year’s. The laws, spearheaded by health care providers, generally narrow when and how prior authorization can occur and create stricter timelines for the review.
Legislators in several states, including Indiana, Nebraska, North Dakota, Virginia, and Washington, have introduced prior authorization bills this year.
In Montana, local health insurers aren’t quietly giving in to increased regulation.
They note that state regulation of prior authorization affects only about a fourth of Montanans with health insurance because large, self-insured plans managed by national health insurers are under federal rules.
State restrictions on prior authorization will increase costs primarily for three in-state insurers, they say — and, eventually, their customers.
“We feel like our job is to say, ‘Is that the best use of money for our membership?’” Jackie Boyle, senior vice president of external affairs for Mountain Health Co-Op, said of prior authorization. “If we approve something, we are doing it for every patient like them.”
Mountain Health, based in Helena, insures 55,000 people in Montana, Idaho, and Wyoming.
Democratic state Rep. Jonathan Karlen of Missoula is sponsoring two bills: one to remove prior authorization for most generic drugs, inhalers, and insulin, and another that says patients can’t be denied a drug when they switch insurers and are waiting for authorization from the new insurer. The second bill also says a procedure or treatment may be denied only by a physician with a matching specialty.
Karlen said insurers are putting up barriers to care to increase their profits and said it’s time to break those barriers down.
“People should be making medical decisions based on what they and their doctors think, not what their insurance company thinks,” he said. “If a doctor says you need a medication, that’s why you have insurance — so you can get that.”
Republican state Rep. Ed Buttrey of Great Falls said he plans to introduce a bill to help kids with chronic bowel diseases, such as the Volpes’ son, imposing a seven-day limit to decide whether to authorize expensive biologic treatments. If insurers don’t meet the deadline, the drug would be automatically approved.
Buttrey’s bill also would eliminate most retroactive denials — when insurers refuse to pay for the treatment they’d authorized.
State Sen. Vince Ricci (R-Billings) said he is preparing other bills that may include even stronger language to restrict prior authorization for drugs for various conditions.
Healthcare providers and patients have heard the rationale of insurers and promises that improvements will be made, but they say nothing has happened and that it’s time for the state to step in.
“When there are no consequences and no teeth to anything, I can complain all I want, but it doesn’t seem to incite change,” said Kim Longcake, the pediatric nurse practitioner who’s treating the Volpes’ son.
Longcake said she and another specialist in her office tracked the time they spent on prior authorization requests in a two-week period.
“Depending on where you want to see me, I’m booking out four to six months,” Longcake said. “If I wasn’t spending 12 hours a week doing prior authorization stuff, it would improve access to care.”
The Volpes said their son, now 13, couldn’t absorb food and didn’t gain any weight for a year and a half while he went through treatments that didn’t work and repeated preauthorization waits, including for his current treatment, which appears to be working.
“What he’s gone through at that age was really excessive, beyond what was needed for treatment, because we couldn’t get the care that he needed,” his mother said. “If we didn’t get switched to this medication, he’d still be doing that.”
CMS is taking complaints more seriously about denial of care by payors. United Health Care, which has been on the carpet because of its high denial rates for prior authorization appealed and won its case against CMS for downgrading the Medicare Star rating from a five to a four because of a phone call from a patient. What was the lawsuit about?
- UnitedHealth alleged that CMS lowered its ratings based on a single unsuccessful phone call from a CMS test caller.
- UnitedHealth claimed that CMS was arbitrary and capricious in docking the star ratings based on a single call.
- UnitedHealth said that an error by the test caller was responsible for failing to connect with a representative.
- What was the outcome?
- The judge ruled that CMS violated the Administrative Procedure Act of 1946 by incorrectly marking the test call as unsuccessful.
- The judge ordered CMS to recalculate the ratings without considering the disputed call.
- The ruling could boost UnitedHealthcare's Medicare Advantage earnings by millions of dollars.
What does this mean for other insurers?This ruling could also benefit other insurers with pending suits seeking to boost their ratings. - The judge ruled that CMS violated the Administrative Procedure Act of 1946 by incorrectly marking the test call as unsuccessful.
Charlotte-area patients sue United HealthCare over high bills
A class-action lawsuit filed by UnitedHealthcare patients has reignited conversations about unfair billing practices by healthcare providers and insurers.
What’s happening: The class-action suit filed in Mecklenburg County Superior Court last week is the result of a dispute between UHC and Providence Anesthesiology Associates, which left people with UHC insurance out of network with PAA’s services.
Why it matters: That’s a big issue because Novant Health, one of our area’s largest health systems, exclusively works with PAA for anesthesiology services. So any UHC patient needing anesthesia at a Novant facility between February 2020 and now has gotten an out-of-network bill.
- Many of those patients are new mothers who received an epidural during childbirth.
- Of note: Many of these bills were lowered after individual negotiations with UHC and or help from PAA.
Zoom out: We’ve been reporting on this dispute since September 2020. Some patients say they didn’t know about PAA’s out-of-network status before reading our stories. And some mothers have told us the dispute has caused them to skip the epidural altogether.
[Go deeper: Healthcare provider feud leads to thousands in unexpected anesthesiology fees for new Charlotte parents, Update: They’ve endured miscarriages and breast cancer. Now these Charlotte patients are caught in the middle of a healthcare provider feud, Charlotte moms still face high epidural costs as the healthcare dispute continues]
The lawsuit alleges that UHC “violated North Carolina’s Patient Protection Act by forcing members to use out-of-network providers, then refusing reasonable reimbursement.”
- The suit also says that UHC “subjected patients to unnecessary financial hardship and related stress when it moved longtime provider Providence Anesthesiology Associates out of network.”
- Six Charlotte-area patients, along with PAA, are plaintiffs in the lawsuit.
What they’re saying: UHC sent Axios a statement in response to the lawsuit:
“The fact that Providence has joined a lawsuit focused on the surprise bills that Providence itself has been sending to patients is just the latest example of the extreme lengths to which it will go to protect its egregious billing practices. Providence’s out-of-network charges are 15 times higher than Medicare pays on average, and when insurers don’t pay those exorbitant charges and instead offer market-competitive reimbursement, Providence surprise bills patients. Fortunately, the No Surprises Act will make it illegal for Providence to continue this practice starting in 2022. In the meantime, we will vigorously defend ourselves against the claims in this lawsuit and will continue doing everything we can to protect our members from Providence’s surprise bills.”
Pointing fingers: Over the last year and a half, UHC and PAA have placed responsibility for the dispute on the opposing party. UHC has blamed PAA for charging too much for their services, and PAA has blamed UHC for undercutting anesthesiology groups like theirs.
- Multiple attempts to negotiate and get PAA back in network have failed.
The big picture: The lawsuit, the dispute that caused it and the resulting medical bills highlight the complexities of the American healthcare system.
Currently, measures like the Hospital Price Transparency rule have been implemented to make the healthcare industry more competitive and transparent. But these changes take time. As of right now, reports show that most hospitals are out of compliance with the rule.
[Go deeper: Charlotte hospitals aren’t complying with the price transparency rule, study finds]
The transparency rule is further complicated because the hospital itself may be in-network while the anesthesia group (PAA) is out of network. While the hospital is transparent, PAA may not disclose that the anesthesiology group is out of network. One solution would be for the hospital to disclose proactively the PAA is not in the network. Most patients would not be aware of this practice and at risk for higher charges.
Attorney General Josh Stein’s office says it’s received seven complaints involving PAA, and many other complaints involving UHC, but those are regulated by the Department of Insurance.
Stein says he’s dealt with other cases similar to the PAA/UHC dispute. He sees price transparency as a big part of the solution.
“The biggest problem is the incredible complexity of our health care financing system. Having transparency of the pricing procedures in health systems is a critical first step,” Stein tells me.
Currently, the attorney general says his office is working to determine which hospitals are out of compliance with the price transparency rule.
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