Prior authorization reform heads to governor's desk after final Senate approval

Legislation focused on prior authorization reforms is headed to the governor after Senate lawmakers approved changes to the bill Wednesday. Lawmakers said the bill is an important step in addressing health care costs for Hoosiers.

The current version of Senate Bill 480 prohibits private insurance companies from requiring prior authorization for the first 12 physical therapy or chiropractic visits for new injuries or "episodes of care."

The author of the bill, Sen. Tyler Johnson (R-Leo), said some of the other changes made in the other chamber focused on ensuring the bill's language worked with health care reform legislation that came out of the House.

Those changes focus on what's known as clinical peer review — where someone with a similar level of experience and training must be in charge of approving or denying prior authorization claims.

"We took the clinical peer language we had and we married it up with the House version that was in [House Bill 1003] there was a small piece of that bill, kind of came up with the best option," Johnson said.

Johnson said the Senate approved SB 480 with the language that lawmakers agreed on.

Under the bill, prior authorization reviews that concern certain specialties have to be reviewed by a physician in the same specialty who is certified by the American Board of Medical Specialties or the American Osteopathic Association in that specialty. For example, an order submitted by an OB-GYN that concerns care relating to that specialty would need to be reviewed by a board-certified OB-GYN.

If the review concerns a specific subspecialty, the reviewing physician also has to be certified in that subspecialty. This means a review concerning an order from a maternal-fetal medicine specialist couldn't be handled by an OB-GYN — the law would require another maternal-fetal medicine specialist to review it.
 

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Similarly, orders submitted by advanced practice registered nurses are also required to be reviewed by a clinical peer who holds the "equivalent or similar" popular focus or role speciality. That review has to be done by an APRN who is licensed in the state, has been granted reciprocity to practice in the state or is licensed in a state that is part of a nursing compact with Indiana.

Sen. Andrea Hunley (D-Indianapolis) said there was a lot of work that went into this bill during the session.

"I know that we've got a ways to go to make sure that we've really tackled this prior authorization piece, but I think that this is a very important start," Hunley said.

Hunley said she was grateful to Johnson for working with various stakeholders in between legislative sessions to understand what reforms were needed in the space.

The legislation did go through significant changes throughout the entire legislative process — including most of Johnson's key proposals in the original measure being removed by the Senate Appropriations Committee over fiscal concerns.

Johnson said the bill is in a good spot. But, he has said throughout the rest of the process he plans to pursue stronger reforms in the future.
 

Abigail is our health reporter. Contact them at aruhman@wboi.org.