Health insurers again win lobbying battle with doctors and hospitals over prior authorization of procedures, treatments

By Melissa Patrick
Kentucky Health News

A bill to exempt health-care providers who have 90% or more of their claims approved from health-insurance companies' requirements for prior authorization of ceratin treatments has failed again. 

"Unfortunately House Bill 317 looks like it's dead," said its sponsor, state Rep. Kim Moser. "We tried in good faith to work out a compromise and we did not have the same reciprocation. And so, you know,  I'm not exactly sure why it didn't get a hearing." 

HB 317 was placed in House Banking and Insurance Committee and had two of its three required readings to be heard on the House floor, but it was never called up for a hearing. The last regular day for final passage of a bill is Thursday, March 28.

Moser said her bill is important because it would ensure timely treatment and care that has been prescribed by a person's health care provider. 

Rep. Kim Moser

"It's really about making sure that patients get the care that they need when they need it," she said. "I think that there is a way to find a process that expedites the care that patients can get – and this is it." 

Asked what concessions she had made with the insurance companies, Moser said, "We removed Medicaid, which was huge." 

That only left the 450,000 patients on the state-regulated plans, which would have provided a snapshot of whether the change would work, she said. 

"We weren't calling it a pilot, but you know, it would allow us to really look at how this helped, or if it didn't help at all," she said. " And, you know, that's all we wanted was to be able to see how it works and see if this is a process that, like I said, (would) expedite the care that patients can receive." 

Physicians say the system undermines their medical judgement, and increases their administrative costs. 

“The current prior authorization process leads to delays for patients, administrative burdens for physicians, and increased costs,” KMA President Dr. Michael Kuduk said in a Feb. 21 news release.  “It’s time for us to pass a common-sense solution that doesn’t harm our patients or overburden our healthcare system.”

Allowing exemptions based on past performance has been dubbed a "gold carding program." KFF Health News reported Feb. 12 that five states have passed some form of it: Louisiana, Michigan, Texas, Vermont and West Virginia, and the American Medical Association is tracing active gold-carding bills in 13 states. 

Kentucky won't be one of them, at least this year, despite the strong lobbying efforts of the Kentucky Hospital Association and the Kentucky Medical Association. Moser said this is the third year she has worked on this effort. 

Asked about the bill's failure, Cory Meadows, KMA's deputy executive vice-president and director of advocacy, issued a statement saying the groiup "is extremely disappointed by HB 317's failure to pass during the 2024 legislative session. KMA members expressed the need for changing the prior-authorization process used by insurers that limits, and in some cases prevents necessary health care to Kentuckians. Throughout these past several months, citizens from around the commonwealth also shared their own stories of how the prior-authorization system impacted their lives, clearly showing that nearly everyone except insurance companies see the need to change this system.

"We're encouraged by the overwhelming bipartisan support the measure received and remain extremely optimistic that with continued advocacy from our members and the public, as well as collaboration with lawmakers, this critical legislation, which proposes to streamline the prior authorization process and ensure patients have timely access to care will soon be enacted. Otherwise, insurers will continue to pocket the money that could make Kentuckians healthier."

The hospital association also expressed its disappointment. 

"Prior authorization is a huge burden on physicians and nurses at our hospitals. And you know, it's contributing to burnout. And so we definitely support legislation that would minimize that burden, as many as has been passed in other states, and we would love to see a pass here," KHA President and CEO Nancy Galvagni told Kentucky Health News. 

Health insurers say prior authorization prevents unnecessary care and ensures that the care meets the standards of best practice. 

The Kentucky Association of Health Plans, the trade group for companies selling health insurance in Kentucky, issued a one-pager in opposition to HB 317 that said, "Prior authorization stops inappropriate care and procedures and heads off dangerous drug interactions and duplicative or inconsistent care, providing a whole-person approach to each plan member’s care needs. Plans help protect against predatory behavior."

Asked about the bill's demise, Tyler Glick, KAHP spokesman, issued this statement: "The health mandate statement generated by the Department of Insurance says the bill would cost up to an additional $11.29 in health-insurance premiums per member per month. That means a family of four would pay an additional $541.92 a year. How is saddling taxpayers (Medicaid), state employees and teachers (Kentucky Employees Health Plan), and everyone else in the commercial insurance market with these costs sound policy? Kentuckians deserve better."

Glick added, "KAHP will continue working with all members of the General Assembly to promote affordability, expose waste and fraud, and provide safeguards to patients."

Moser said she's not giving up on this effort and will likely work on it during the interim.

"The burdens of prior authorization are not going away anytime soon," said Galvagni. "And I'm sure the issue will be back. And, you know, we look forward to continuing to work on that."