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“Should Indiana prohibit prior authorization in health care?”
Even if you’ve never heard the term “prior authorization,” there’s a good chance you’ve been affected by it.
Prior authorization—“prior auth” for short—refers to a practice used by health insurance plans to require a preemptive review of a planned health service before insurance will agree to pay for that service.
Prior authorization was originally intended to serve as a cost-containment tool, but it has become a huge burden for patients and providers alike. That’s why I authored a caucus priority bill in the Indiana Senate last session that aimed to reform multiple areas of concern with prior authorization procedures. This bill was not passed into law, but I plan to continue these efforts during the 2025 legislative session to ensure Hoosiers are getting the care they need in an efficient and cost-effective manner.
When examining the current system, I found that it seems to be set up to create frustrations and delays in care for the patients. The focus of my efforts is to change the system so that patients are the top priority.
The notion that prior authorization contains health care costs is highly questionable since it drives up administrative costs to practices and increases insurance premiums for patients. The manipulation of prior authorization is also affecting patients’ ability to get the services they need by inappropriately denying and delaying care. That’s a double whammy for patients: They are paying higher premiums for insurance that isn’t effectively helping cover the costs of the service and medications they need.
Indiana should enact laws to fix this broken system by placing needed limitations on how insurance providers use prior authorization, such as:
◗ prohibiting health plans from requiring prior authorization for routine services;
◗ limiting the ability of health plans to change preapproved prior authorization requests;
◗ speeding up decision deadlines for health plans so the system does not slow down or stop the patient’s ability to receive care; and
◗ requiring prior authorization decisions to be made by licensed doctors with experience and a specialty in the condition being reviewed.
I have spent the last year in numerous meetings with various stakeholders, including businesses, patients, physicians, hospitals, pharmaceutical companies, insurance companies and legislators across Indiana to develop, reform and improve the prior authorization process for the patient, because Hoosiers deserve access to health care they can trust.
These changes would help limit the abuse of prior authorization by health plans and place the focus back on identifying waste, fraud and abuse. I’m not seeking to do away with the prior authorization system but to reform it so the value is placed back on the patient, and Hoosiers are able to access the care they need.•
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Johnson, an ER doctor and Republican, represents District 14, which includes Allen and DeKalb counties. Send comments to ibjedit@ibj.com.
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Data shows that Prior Authorization (PA) does not reduce overall costs or improve quality of care. PA is a “speed bump” to slow utilization. Most denials are eventually approved, but after lengthy, complicated, costly, and often dangerous delays. Patients have little insight into what hospitals and physicians must go through to get them the care they need. There is lack of transparency regarding criteria used by payers for approval. Clinical practice guidelines are published by a variety of medical professional societies giving expert, evidence base guidance to clinical decision making. But even these tools are limited (only about 20% of recommendations are supported by multi-center randomized clinical trials), the majority of clinical decisions are based on individualized clinical judgement supported by applicable clinical evidence. IN should not have to reinvent the wheel. States like TX, VA, MD, IL, CO, OK, and others have already passed laws restricting PA. The US Congress has passed legislation to restrict PA in Medicare Advantage plans. Even the state of IN has considered laws to limit PA that involves state employees. The discussion regarding PA has been going on for more than 10 years. The ongoing “discernment” by payers is nothing more than foot dragging.