Prior Authorization Reform–What is Act 146 and What Does it Mean for Physicians? Sara Hussey, MBA, CAE—ACMS Executive Director On November 3, 2022, Pennsylvania Gov. Tom Wolf signed PA Senate Bill 225 into law as Act 146. This new law does not eliminate prior authorization, but it does aim to streamline the prior authorization process. It provides parameters that govern the relationships between patients, providers, and insurers for health care coverage decisions. Pennsylvania will now join 44 states that already have external review authority. In addition, the new law also lays out standards for the review of prior authorization requests and confirms in state law that there may be no prior authorization for emergency services, consistent with the Federal No Surprises Act. When it comes to legislation, you might feel overwhelmed as soon as you start to dig into a new bill or law. Having that legislation broken down into simpler, bite-sized pieces can be helpful in understanding the breadth of its impact. With the help of the legislative team at PAMED, I’ve created a summary of some of the main components of Act 146.
What is Act 146? At its core, the legislation streamlines the prior authorization process, improving the sequence of events, ending with a quick and timely turnaround to move patient care forward. Phase 1—Begins January 2023 Meet the New Provider Portal: Within 18 months of the effective date (01/2023) of this specific section of Act 22
146, insurers/MA/CHIP are required to have established a provider portal on their publicly accessible website that includes electronic submission of prior authorization requests, access to applicable medical policies, information regarding how to request a peerto-peer review, contact information for the insurer’s relevant clinical or administrative staff, and instructions for submission of prior authorization requests if the portal is unavailable for any reason. Within six months following the establishment of a provider portal the insurer/MA/CHIP shall make access to training available to health care providers and their staff on the use of the portal. This is Section 2153 of Act 146 and it is the first section that will go into effect. The rest of Act 146 will go into effect January 2024.
CHIP has a medical policy that includes step therapy criteria for a prescription drug it must include, as part of its prior authorization process, a request for an exception to its step therapy criteria. A request for an exception shall be evaluated based on the covered person’s individualized clinical condition and consider contraindications, clinical effectiveness of required prerequisite drugs, expected clinical outcomes of the requested drug and whether the required step therapy criteria has already been satisfied under a previous insurer.
Phase 2—January 2024 Closely Related Procedures: Act 146 will allow physicians to bill insurance companies for “closely related procedures”. This means that if a patient is getting care for an already covered issue, and the doctor identifies a condition that could lead to future complications, the doctor can address the condition immediately without having to get second authorization for a service. Emergency Services: Section 2116 of Act 146 states that insurers/ MA/CHIP can’t require a health care provider to submit a request for prior authorization for an emergency service. Step Therapy: Act 146 will create a basic framework for step therapy requirements. If an insurer/MA/
Clinical reviewers assigned to conduct external reviews must be a physician or other appropriate health care provider who has expertise in the treatment of the covered person’s condition, is knowledgeable about the recommended health care service, is board-certified in the area of medicine appropriate to the subject of the review and has no history of disciplinary action.
Minimum Qualifications for Independent Review Organizations – AKA “Peer Review”:
Prior Authorization Review: This section – Section 2155 as it’s formally known – encompasses a good portion of Act 146. The team at PAMED was kind enough to share their overall analysis of this new law, which includes a deep dive into Section 2155.
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