This week, legislation concerning prior authorization requests was introduced in the state House of Representatives. The goal of House Bill 19-1211 is to streamline the overall process of prior authorization and promote safe and timely access to evidence-based care for patients by increasing transparency and reducing the variations among payers and utilization management organizations.

The Colorado Medical Society strongly supports prior authorization streamlining. According to a 2018 CMS membership survey nearly one-half of Colorado physicians (48%) say prior authorization has become harder over the past few years, including 28% who say it has become much harder and 20% who say it has become a bit harder.

The legislation as presented includes the following measures.

  • Prior authorization criteria should be current, clinically based and where applicable align with a payer’s other quality initiatives, as well as across all payers. 
  • The legislation allows for selective application of prior authorization. A physician can qualify for exemption from prior authorization requirements based on his or her historical performance. The physician’s performance relative to the payer’s prior authorization requirements will be reviewed/revised annually.
  • The legislation improves transparency of prior authorization requirements. Effective communication, clearly articulating prior authorization requirements, criteria and rationale, will ensure timely resolution of prior authorization requests and minimize care delays.
  • Continuity of patient care is vitally important for patients undergoing an active course of treatment. In the bill a prior authorization approval will be effective for at least 180 days and continues for the duration of the ordered course of treatment.
  • The bill provides for timeliness. A carrier must complete routine prior authorization requests within two days or, for urgent care, make the determination within one day.
  • The legislation allows for prior authorization program reporting, review, and adjustment. Payers will make statistics available regarding approvals, denials and appeals, resulting in an overturn of the original determination. Such analytics and up-to-date clinical criteria should be used to evaluate and improve the payer’s prior authorization requirements.

Stay tuned as this bill moves through the legislative process.

Categories: Communications, ASAP, Legislative Updates