Vermont health care providers blame prior authorization for compromising patient care

Vermont's health care providers have taken aim at health insurance companies, targeting excessive bureaucracy, and the practice of requiring prior authorization for needed procedures and drugs, as compromising patient care and increasing costs, even though prior authorization is intended to lower costs by preventing unnecessary or misguided care.

This week, the University of Vermont Health Care Network distributed a commentary on health insurance practices by Kelly Lange, president of managed care contracting. In addition, the Vermont Association of Hospitals and Health Systems sent out a press release calling for the passage in the Vermont Senate of a House bill that requires health insurance companies to "reduce administrative delays and streamline insurance requirements." Lange called for passage of the bill as well.

What does the House bill that passed unanimously require health insurers to do?

The bill, H.766, passed the House unanimously on March 13 and was introduced into the Senate on March 15, where it was assigned to the Committee on Health and Welfare. The two major insurance companies in Vermont are Blue Cross and Blue Shield of Vermont and MVP Health Care.

The House bill would require health insurers to:

• Align billing practices called claims edits with those used by Medicare and execute prior authorizations according to Medicaid policy. (Claims edits are intended to ensure the accuracy of medical billing.)
• Allow patients and providers to ask for exemptions to "step therapy," a process that allows health insurance companies to require a patient to try one or more less expensive medications before receiving the newer or more expensive medication originally prescribed
• Decide prior authorizations within 24 hours for urgent situations and two business days for non-urgent situations

The bill also directs the Department of Financial Regulation to prohibit prior authorization requirements for certain medication and services, and would require insurers, not providers, to collect cost-sharing amounts from patients.

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"We have been calling on leaders to simplify the prior authorization process for years," Rick Dooley, a physician assistant with Thomas Chittenden Health Center, said in a statement. "But we've seen little action, despite ongoing harm to patients and providers."

Health providers: When we have to ask permission to do our jobs, it drives up costs and endangers patients

Prior authorization requires clinicians to ask permission from insurance companies before a patient can receive services. Lange recounted the experience of a patient who went to neurosurgery at the UVM Medical Center in early March for a serious condition. The specialist recommended more advanced imaging and scheduled an appointment, according to Lange.

The patient was not experiencing an active emergency, so prior authorization was required. Two and a half weeks went by without receiving the authorization, despite multiple phone calls from the UVM Medical Center team. When the patient arrived for her appointment, she was faced with stark options, along with the hospital.

"At that point, the hospital either has to perform the procedure and not get paid − contributing to well-documented financial challenges that make it difficult to provide care to all future patients in need − or tell the patient she may receive a bill for tens of thousands of dollars for a scan her provider told her she needs," Lange wrote. "In this case, thankfully, the authorization finally came in − an hour after the appointment."

Rules for prior authorization change 40 times a week, according to UVM Health Network manager

Lange said that not only do policies on prior authorization vary between insurance companies, but the rules also change frequently, with 2,100 changes every year on average.

"That's 40 per week," Lange wrote. "If it's difficult for our team of experts to stay on top of all these changes, how are patients supposed to know what to do? It's like if the fire department needed approval from the water utility before tapping a hydrant to put out a fire − but only on certain streets."

Will health care costs go up if the House bill is passed by the Senate and made into law?

Dooley acknowledged health insurers have claimed passage of the bill will increase premiums, but said he disagreed.

"Although health insurers may save money in the short term with these practices, the truth is that patients and providers are already paying more for the cost of delayed care and extra administrative work," Dooley said. "Patients end up paying for expensive ER visits or hospitalization, and providers end up taking time they could be using to see patients to make phone calls to justify their treatment decisions to health insurers."

Contact Dan D’Ambrosio at 660-1841 or ddambrosi@gannett.com. Follow him on X @DanDambrosioVT.