Potential health insurance regulations pit providers, lawmakers against companies

But at the second interim meeting of the Joint Commission on Labor, Health and Social Services in Evanston on Thursday, the legislative committee will consider the first draft of pre-authorization regulations proposed by the commission’s working group. The rift that exists between insurers, health care providers and lawmakers has been exposed. group.

Wyoming is the only state in the country that does not have laws regulating “pre-approval,” the process by which health insurance companies decide which treatments and drugs to cover and pay for based on a patient’s plan.

A working group of the commission, led by Sen. Dan Dockstader (Afton R.A.) and Rep. Sarah Penn (R. Lander R.R.), met in May with medical groups and insurance companies to find out what pre-approval they will be accepting going forward. Started formulating rules. for next year’s parliament.

Physicians, other health care providers, and medical facilities complain that preapproval is a false approval system, increasingly wastes time and resources, and delays and interferes with patient care. Insurers claim to act as financial controllers for their members, using this process to manage the quality of care.

At its April meeting in Casper, committee members voted unanimously to draft a bill to curb the power of health insurance companies in Wyoming.as a result 32-page draft bill Thursday’s meeting was met with resistance from insurers, who pointed to a number of issues they said needed to be addressed. They called on the commission to allow businesses and medical groups to continue working with lawmakers to improve the law.

Attorney Bruce Spencer, who represents Mountain Health Corp., said, “We all tried very hard to come to an agreement on what we could agree on, but sometimes we couldn’t, and frankly, we ran out of time.” , which covers the state of Wyoming about 18,000 people.

Between concern Representatives of the Mountain Health Co-op and the Wyoming Blue Cross Blue Shield have proposed data reporting mandates to force information sharing when insurers deny medical services. The bill would also require companies to consult with doctors if they are considering denying treatment on the grounds that it is not a “medical necessity,” which could lengthen the time it takes to approve a treatment. Deaf representatives said.

A bill is currently being drafted that would give insurers five days to approve or deny non-urgent medical requests and 72 hours for urgent requests.

“You’re going to have to stick to a schedule, so you’re going to hold more lines of just denying things,” said Ken Shacher, a doctor, medical director and administrator who works at the University of Utah and Mountain Health Co-op. said. .

The companies also opposed a “gold card” system that would allow doctors to skip pre-approval if their treatment plans are at least 80% approved by insurance companies.

“We don’t use preapproval as a mechanism to avoid paying medical bills,” said Heather Law Day, a lobbyist for the Blue Cross Blue Shield in Wyoming. He said prior authorization ensures that insurers use limited resources effectively, that patients receive the evidence-based care they need, and that providers are compensated. added.

Insurance companies also showed some sympathy. Cheyenne Republican Rep. Dan Zwonitzer, co-chair of the committee, said the bill wasn’t ready until Congress in 2024, and admitted lawmakers were listening to businesses’ concerns. . But others expressed skepticism, echoing the medical groups that spoke out.

“We continue to be unable to provide adequate follow-up care without the disruption of waiting times and delays,” said Dockstader.

“I hope you understand that we also want to protect money. It’s other people’s money and we want to protect it. We want to reach a state where we are not,” he said. Added.

Wyoming Medical Association Executive Director Sheila Bush and Wyoming State Hospital Association President Eric Boley encouraged lawmakers to avoid the insurance company “rabbit hole.” Both said they supported the bill as written and believed only minor changes were needed.

“I think a lot of the conversation this morning was resistance to pre-approval reform, as insurers actively transition to a role in policing safe medical practices,” Bush said. “That’s not how insurance works or how to use it. That’s not their role.”

Boley countered claims that prior authorization helps protect patients and providers.

“I’ve heard from insurance companies that this was not done to contain costs,” he said. “It’s a complete misunderstanding.”

At the commission’s first public hearing in April, testimony from doctors, hospitals and medical groups about the pre-licensing burden shook lawmakers. Dr. Kevin Haring, a Casper-based general surgeon, expressed concern over what he said was a basic blanket denial from insurance companies harming patients and doctors.

“My guess is they’ll say ‘no,'” he testified. “I don’t even know if they read it.”

Lawmakers were again drawn to medical groups on Thursday. When asked if they think insurers should be required to reduce approval times, the majority said they would update the bill to allow companies to set deadlines of 24 hours for emergency care and 48 hours for non-emergency care. voted in favor of doing so.

Dockstader and Penn will again lead a working group to find further agreement between insurers and medical groups ahead of the next health board meeting in Saratoga in September. But so far lawmakers have at least one side’s approval.

“As far as I’m concerned, we’re ready,” Bouley said in a statement, to which Sen. Anthony Bouchard (Republican, Cheyenne) responded.