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Bill to simplify medical insurance in Pennsylvania heads to Governor’s desk

Sam Dunklau / WITF The Pennsylvania Capitol building in Aug. 2022.
Sam Dunklau / WITF The Pennsylvania Capitol building in Aug. 2022.

TRANSFORMING HEALTH - Pennsylvania state lawmakers have passed a bill that supporters say will make it easier for doctors to treat patients by streamlining how they work with health insurers. Democratic Gov. Tom Wolf is expected to sign the bill into law.

The bill, sponsored by Republican state Sen. Kristin Phillips-Hill of York County, focuses on a part of the insurance approval process called prior authorization. Before a doctor prescribes a medication or treatment, they have to check whether it will be covered by the patient’s insurance, said Dr. Arnold Baskies, a surgical oncologist based in New Jersey who regularly works with patients from eastern Pennsylvania.

“You really don’t want to stand in the way of somebody’s treatment,” Baskies said. “It’s a very bad idea, and insurance companies have been getting away with it, to be honest with you, for a long time.”

Baskies said this bill changes all that. It bars prior authorization requirements for most emergency room services. Insurance companies have to promptly state what they’ll authorize. When they deny something, they have to give written notice. And patients can appeal the decisions to the state insurance department.

A related concept, “step therapy,” requires patients to try treatments chosen by the insurance provider before other treatments — which the doctor may prefer — are covered. Baskies noted, with this bill, doctors can now request a “peer-to-peer review” with a doctor working for the insurance company to discuss the need for a different treatment.

Pennsylvania Insurance Federation President Sam Marshall said he supports the bill, calling its passage a “collaborative and bipartisan effort” that followed industry best practices.

“Prior authorization helps patients to get quality and affordable care,” Marshall said. “Questions about medical necessity are best resolved before, not after, the care is provided. This bill will ensure that happens in a consistent way that is understandable for patients, providers and insurers.”

Hospital and Health System Association of Pennsylvania President Andy Carter said the law will remove barriers for people who need health care.

Carter said the legislation “establishes clear and predictable processes that will reduce delays in medically necessary care for patients, while also lessening costly administrative burdens for hospitals and health care providers.”