The North Carolina House and Senate have both introduced legislation to reform the prior authorization process.
There is no denying that the prior authorization process can be improved for patients, and these bills have brought the issue to the forefront.
In some ways, the two pieces of legislation are similar.
Both include measures to increase transparency and require insurers to clearly disclose prior authorization policies.
Both also tighten turnaround times that are already required by law.
These are positive reforms.
However, the bills also differ in some substantial ways.
Most notably, while the Senate bill focuses on improving the process for patients, the House bill appears to be more concerned with easing “administrative burdens” for provider practices, even if that comes at the expense of the patient.
For example, the House bill exempts providers from prior authorization if 80 percent of their claims are approved.
North Carolinians should not be comfortable with only a four-out-of-five success rate from their doctors, especially if you are the patient whose care was inappropriate, excessively expensive, or dangerous.
As a state, we should also not accept up to 20 percent opioid or fentanyl prescriptions to not meet established medical standards, for example.
An 80 percent threshold it is dangerously low for patients.
Second, the House bill adds administrative requirements and restrictions that will put patients at risk for increased costs and safety gaps.
If insurers cannot check that care is covered before it is administered, then patients are left vulnerable to high surprise bills.
Or if a provider sends a test to an out-of-network lab, patients would be responsible for the excess cost.
Adding so many administrative requirements and restrictions also undermines patient safety.
It would mean that prior authorization could not be used to help enforce prescribing limits on opioids and protects patients from being targeted by fraudulent addiction treatment facilities.
Lastly, the House Bill fails to address the underlying problem that the cost of healthcare is too high.
If the bill addressed the cost problem, then it would also apply to the State Health Plan. By excluding the State Health Plan, the bill exempts lawmakers themselves who get health insurance through the state.
There is no denying that the prior authorization process can work better for patients, and the fact that both chambers have put forward proposals is a positive development.
But for those reforms to be meaningful and positive, they must be patient focused. That means increasing transparency and improving the process, without raising costs or risking safety.
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