Lawmakers Seek To Rein In Red Tape In Medical Insurance Claims

Oregon lawmakers are targeting some of the red tape in medical insurance claims that can delay treatment for patients. 

House Bill 2517 would require insurers to provide information about prior authorizations, and it would revamp the so-called “step therapy” process that unfolds when insurers require providers to first try a less expensive treatment on patients before proceeding with the physician’s recommended treatment. Step therapy rankles patients and providers alike because it delays care. 

The measure has passed the House and is now in the Senate Health Care Committee, which met on Monday. The bill has support across a broad swath of the medical community, including oncologists, ophthalmologists, chiropractors and naturopathic physicians. 

The step therapy process can differ among specialities. A dermatologist told senators on Monday that in his specialty, insurers often require providers  to prescribe outdated treatments when more advanced -- and safer -- options are the best choice.

“These programs create layers of paperwork for providers and cause delays in patients getting the treatment originally prescribed by their physician,” wrote Dr. Andrew Blauvelt, a dermatologist and president of the Oregon Medical Research Center in Portland, in a letter to lawmakers.

The requirements also can cause harm, providers said.

“Patients should not lose their lives waiting for insurance companies to approve procedures or life saving medications,” said Rep. Rachel Prusak, D-Tualatin  and West Linn. A nurse practitioner, she’s co-sponsor of the bill with Sen. Bill Hansell, R-Athena.

The bill doesn’t ban step therapy. But it would allow providers to bypass required treatments in certain circumstances, such as if a patient had unsuccessfully tried a medication in the past so they wouldn’t have to retry it again. 

Providers and patients say they need the change to access care in a timely manner. The Oregon Society for Medical Oncology urged lawmakers to pass the bill to help patients with a narrow window to fight back cancer. 

“Step therapy or fail first policies can be problematic for patients with cancer because they can severely delay a patient’s access to the best treatment available for their condition,” the group wrote in a letter. “While many treatments preferred by payers are less costly financially, they may not be the best treatment available for the patient. While waiting to complete a ‘step,’ a patient with cancer may experience disease progression and irreversible damage to their overall health.”

Traciee Thomas, who suffers from eczema, told lawmakers that people with the skin condition suffer in silence as they and their providers face pushback from insurance companies. 

“This leads to delayed positive outcomes in terms of resolving eczema flares or at least making them manageable,” Thomas, who lives in the Portland area, told lawmakers. “Imagine having an itch so ferocious that no matter what you used to scratch it, you received no relief, or you scratch and scratch until you draw blood.”

Blauvelt, the dermatologist, said step therapy forces dermatologists to first prescribe outdated and potentially harmful treatments. He cited treatments  for psoriasis, a chronic skin condition, as an example. Insurers might require providers to first use methotrexate, a drug which comes with “black box warnings against its use, including potential bone marrow, liver, lung, skin, and fetal toxicities,”  Blauvelt wrote.

Or they might first require treatment with phototherapy, which became widely used in the 1980s. Phototherapy requires visits to the doctor’s office two to three times a week and can eventually cause skin cancer, Blauvelt said. 

In contrast, newer treatment options require less monitoring and do not pose a toxic risk to organs. They also have a vastly better success rate of 90%, compared to 25% for methotrexate treatment, he said. 

“Yet, still today in 2021, dermatologists are invariably posed with the non-scientific practice of being forced to have their psoriasis patients try and fail 20th century treatments before being allowed to prescribe targeted 21st century medicines,” he wrote to lawmakers. 

The bill sets up limits. For example, it would not allow step therapy when the less expensive treatment could harm the patient, or when the patient has benefitted for at least 90 days from the desired treatment and could be harmed by a  change in treatment. The bill also prevents step therapy when the insurer’s desired treatment is not in the patient’s best interests based on “medical necessity.” 

Providers must show documentation to the insurer in order to receive an exemption. 

Cambia Health Solutions, which owns Regence and BridgeSpan, raised concerns about the bill’s “medical necessity” provision.

“We believe adding a medical necessity exception will create less certainty over the exception process since there are often differing opinions over what is medically necessary,” Vince Porter, director of government affairs for Cambia, wrote in a letter to lawmakers.

The bill also targets the so-called “prior authorization” process, which is when providers need authorization from insurers before proceeding with treatment. 

Hansell, the bill’s co-sponsor, said a friend died waiting for authorization for  doctors to operate on him after he suddenly became ill with an aneurysm. 

‘’No one’s life should hang in the balance while waiting for prior authorization,” Hansell said.

The bill would require coordinated care organizations to report annually to the Oregon Health Authority the number of requests they receive from providers for prior authorization, the initial and reversed denials and the reasons for the denials. The state contracts with coordinated care organizations to provide Medicaid coverage to Oregonians. 

The bill would require other commercial insurers to provide the same information to the Oregon Department of Consumer and Business Services. 

The bill also changes the process to appeal denials from insurers. Currently, that  process involves an independent group that reviews claims and makes a determination on appeals. The bill would require those independent groups to have at least one member who is a clinician. That provider would have the same or a similar specialty as the clinician in the appeal.

The bill also would require insurers to post online the treatments, drugs and devices that they review before they grant authorization. Insurers would have to provide a 60-day notice when they change their requirements for prior authorization as well. 

Providers and medical groups say they sorely need the change. 

“The criteria used for prior authorization are often unclear and vary between insurers,” Courtni Dresser, director of government relations for the Oregon Medical Association, said in submitted testimony to lawmakers. “Health care providers rarely know at the point-of-care if the prescribed treatment requires prior authorization, and only find out later when a patient’s access is delayed or denied. Furthermore, providers are often required to repeat prior authorizations for prescription medications when a patient is stabilized on a treatment regimen for a chronic condition.”

Oregon lawmakers considered a similar bill in the 2020 session, which died with most other bills during the GOP legislative walkout to kill a carbon tax bill.

Since 2019, 19 other states have passed similar legislation, including California and Washington. 

The committee heard testimony on the bill Monday without taking action. 

You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.