“Reforming prior authorization practices of insurers is a top priority for the North Carolina Medical Society.” – Dr. Karen Smith

RALEIGH — The State Health Plan Board of Trustees met Thursday in Raleigh.  At the meeting, North Carolina Medical Society Board of Directors member Dr. Karen Smith presented on behalf of NCMS on prior authorization reform.

“Two decades ago, we fought against these abusive practices, and unfortunately,” Smith said, “they have resurfaced in a new form.”

Smith thanked the Board for requesting an analysis of prior authorization, which she says can deprive both employers and employees of coverage they have already paid for.

She encouraged the Board to act on behalf of the nearly 9,000 members of the NCMS to take swift, decisive steps to adopt comprehensive reforms, akin to those outlined in House Bill 649: Ensure Timely/Clinically Sound Utilization Review.  This bill passed the North Carolina House of Representatives with unanimous support and is based on proven, effective models used by the American Medical Association and states that have successfully tackled these issues. 

Here are the common-sense reforms recommended to the Board:

• Requiring insurers to make utilization review requirements and restrictions transparent, easily understood, accessible to the public, and updated annually based upon clinical standards.
• Mandating that insurers communicate with the treating physician and patients prior to denying any recommended care.
• Requiring that the physician reviewing denied care be licensed in North Carolina, have the same or similar credentials as the treating physician, and have experience treating patients similar to the one filing the appeal.
• Ensuring timely decisions based on the urgency of the required care.
• Addressing continuity of care and retrospective denials, concerns highlighted in your presentation, which we commend Segal for recommending.

Smith added that “physicians across the state have shared alarming stories about how prior authorization has negatively impacted their patients’ health.  The current process used by insurers often causes unnecessary delays in treatment, leading some patients to abandon life-saving care.”

Smith also pointed to statistics from the American Medical Association that say physicians and their clinical teams spend an average of 13 hours per week  — nearly two business days — on prior authorizations, time that could be spent on actual patient care.

Also speaking on behalf of prior authorization reform was Greg Griggs, EVP of the NC Academy of Family Physicians.  He added to the voice of physicians and PAs saying “the time for reform is now.”

See a portion of her comments at the meeting below.

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