Senate approves significant health care overhaul on prior authorization, step therapy


HARRISBURG – The Senate unanimously approved landmark legislation that streamlines the prior authorization and step therapy processes for medical treatment, according to Sen. Kristin Phillips-Hill (R-York), who sponsored the measure.

Senate Bill 225 would set standards for commercial insurance plans as well as Medicaid plans when seeking prior authorization approval, as well as step therapy protocols. The legislation would also provide a timely process for appeals determinations.

Prior authorization refers to any process by which physicians and other health care providers must obtain advance approval from a health plan before a specific procedure or service is delivered to the patient to qualify for payment coverage. The process was initially created to control costs for experimental or new procedures. Step therapy requires patients to try one or more prescription drug treatment option(s) chosen by the patient’s insurance provider.

“This measure will strengthen relationships between doctors and patients, as well as cut red tape that will ultimately lead to better health care outcomes,” Phillips-Hill said. “This is not a Republican or Democrat issue – this is about finding efficiencies and negotiating between health care providers and insurers to come up with reforms that will ultimately benefit patients across the Commonwealth.”

The legislation would require insurers to provide timely approval for both non-urgent and emergency health care services to health care providers before services and treatment are rendered. The proposal would also spell out guidelines for prescription drug step therapy, as well as options for patients and heath care professionals to obtain an exception to best serve the patient and his or her treatment plan.

A recent survey of physicians by the American Medical Association found 78% of doctors note that prior authorization delays can lead to their patients to abandoning their treatment, while 91% of doctors indicate prior authorization delays can lead to negative clinical impacts on patients.

The bill goes to the House of Representatives for further consideration.

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