Advocacy

How to support PRS Advocacy

Join the PRS Advocacy Committee: The PRS membership is diverse - and each member’s unique medical knowledge and contributes to PRS’s advocacy efforts.

Wondering how much time you can commit? The Advocacy Committee welcomes whatever commitment your schedule allows.

Educate yourself: Check out the  legislative tracking list and our legislative updates. Take a moment to peruse ACR’s and CSRO’s websites for mutual topics of concern The AMA, the Pennsylvania Medical Society website also feature advocacy sections.

Provide input to PRS leadership and PRS Advocacy Committee: We need your input into our legislative priorities. As we look ahead to the next two-year legislative session we want to to ensure we are representing your concerns.

and…

Be ready to act: When you receive an Action Alert from us, be ready to act.
  When we call for volunteers to share our message at state and national level, be ready to act.
  When we need member input on proposed legislation or policies that impact rheumatology, be ready to act!

November 2022
PRIOR AUTHORIZATION LEGISLATION SB225 PASSES AND IS SIGNED INTO LAW

A Message from Dr. Michael Borofsky, Advocacy Committee Chair:
Good News PRS Members!

Senate Bill 225 (Prior Authorization) was passed in the PA House and has been signed into law as Act 146 of 2022.

The implementation of the amended provisions within the bill is a substantial victory for physicians, patients, and their families. While Senate Bill 225 does not completely eliminate prior authorization requirements by insurance companies or any other private or commercial payers, it greatly reduces impediments to timely medical care and reduces administrative burdens.

We are pleased to stand with our colleagues at the Pennsylvania Medical Society, who led grassroots advocacy efforts that ultimately advanced passage of the bill. Thanks to all PRS members who assisted in this effort.

READ Act 146 of 2022

ACT 146 OF 2O22- PRIOR AUTHORIZATION REVISIONS
Analysis by Deborah Shoemaker, PRS Lobbyist

Background
Senate Bill 225 (Printer’s Number 2004) amended Article XXI of the Insurance Company Act of 1921. This section of the Act, entitled Quality Health Care Accountability and Protection, oversees the responsibilities of Managed Care Organizations (MCOs), and health care insurer’s complaint, grievance and utilization review practices.

Senate Bill 225 received final approval in the state House and Senate on October 26th. Governor Wolf signed the bill into law on November 3, 2022, as Act 146 of 2022.

Key Provisions of Act 146 of 2022
Extended Oversight Act 146 now applies to Medicaid, the Children’s Health Insurance Program (CHIP) and all commercial insurance plans doing business in the commonwealth. All MCOs, public insured entities and all commercial payers are now required to comply with the provisions of Act 146.

Emergency Services - including any screenings/testing performed while stabilizing a patient in the emergency department- cannot require prior authorization.

Provider Portals must be made available by all insurance plans/MCOs for electronic submission of prior authorization requests (Section 2153).

Prior Authorization Guidelines All prior authorization guidelines and internal policies must be posted on the MCO/insurer’s portal for provider and enrollee reference.

Review and Denial Any clinical review/denial of prior authorization claims must be internally reviewed by a medical professional within the same clinical area of medical expertise as the provider requesting a claim review.

Clinical Review Standards must be based on nationally recognized standards and current medical/scientific evidence (including Evidence Based and Promising Practices as published in peer-review literature).

Review of step therapy prior authorization must take into consideration the patient’s clinical prescription history (including prior completion of step therapy), including contraindications, past clinical outcomes, expected clinical outcomes and potential clinical outcomes (adverse or positive) for prerequisite drugs.

Response time for Medical Prior Authorization requests For new medical prior authorization requests, the insurer must return a response within 72 hours for emergency requests and no more than 14 days for non-urgent medical services.

Response time for Prescription Prior Authorization requests For new prescription medication and/or step therapy prior authorization determinations, a response must be provided within 24 hours for emergent issues and no longer than 72 hours for routine claims.

Submission of Additional Information If crucial clinical information is not provided in the initial claim, the provider must be contacted within 24 hours for emergent claims and 2 days for non-emergent requests. As soon as provider submits the requested information, a response must be obtained within 48 hours.

What does this mean for rheumatologists ?

Provisions in Act 146 of 2022 do not prohibit MCOs or insurers from implementing cost containment measures (such as step therapy, fail-first, or prior authorization).

However, for the first time, patients will be able to obtain simple, clear information when procedures are denied (including information on how to appeal).

For PRS member practitioners, all insurers must abide by the same rules- leveling the playing field, making it easier to streamline the prior authentication process.

We believe the passage of Act 146 is the first step toward reducing administrative barriers for our frontline staff in obtaining reimbursement from insurers and assisting our patient in receiving more timely treatment and services.

Implementation Dates

Section 11 (Repeals) and Section 12 (Continued Provisions) went into effect immediately.
Section 2153 (Creation of the Provider Portal) goes into effect on January 1, 2023.
All other provisions of the Act must be implemented no later than January 1, 2024.