Prior authorization transparency for health plans

Summary#

SB 1163 would create new Wisconsin statutes on prior authorization and amend existing statutes to apply the rules to certain state, local-government, school, and cooperative health plans. Its stated goal, reflected in the bill’s title, is to increase prior authorization transparency and allow exemptions for providers with high approval rates. The bill failed, so it did not change current law.

  • Health care plans would have to publish a complete list of services requiring prior authorization, plus current requirements, restrictions, and clinical review criteria. Some information would have to be available to the public without an account.
  • Plans would have to give contracted providers at least 60 days’ written notice before new or changed prior authorization requirements take effect, and update their website before implementing the change.
  • Clinical review criteria would have to meet listed standards, including being evidence-based and reviewed at least once a year.
  • Plans could not deny a claim because prior authorization was missing if the requirement was not in effect on the service date. They also could not treat certain supplies or services as incidental, or deny their claims, when the associated service received prior authorization or did not require it.
  • The insurance commissioner could make rules requiring plans to exempt some providers from prior authorization for specified items or services if the providers meet an approval-rate threshold set by the commissioner.

What it means for you#

  • Enrollees and the public: If the bill had become law, you could have looked up which services require prior authorization without signing in. The more detailed requirements and clinical criteria would have to be accessible to enrollees and providers.
  • Health care providers: Contracted providers would receive at least 60 days’ written notice of planned changes. A provider might qualify for an exemption if the commissioner set rules for it and the provider met the required approval rate. The bill does not itself set that rate or guarantee an exemption.
  • Health plans: Plans would have to maintain and publish the required information, meet the notice and review-criteria rules, and follow the claim limits. The bill also names state health coverage, certain local-government and school self-insured plans, and cooperative nonprofit health plans in amendments applying the new provisions.
  • General public: The bill would not end prior authorization or directly change what health care a plan covers. It would set disclosure and claim rules and let the commissioner create an exemption system by rule.

Money#

No cost information is included in the available material.

  • Plans would have to update websites, provide notices, and meet the clinical-criteria requirements; the cost to do so is not stated.
  • The bill gives the commissioner rule-making duties and powers, but provides no estimate of the cost of administering them.
  • The bill’s analysis refers to a state fiscal estimate, but that estimate was not supplied.

What is unclear#

  • The current versions of the statutes being amended were not supplied, so the bill’s changes could not be checked against all current law.
  • The definition of “health care plan” is in a statute not supplied here. The full range of plans covered by the disclosure rules therefore could not be verified.
  • The commissioner would set the approval-rate threshold, evaluation period, eligible items or services, and exemption process by rule. The bill does not set those details.
  • The bill does not set a start date for an exemption system or explain how providers could challenge an exemption decision.
  • The bill sets website and notice duties but does not specify penalties or a complaint process for violations.

Case for#

  • A public list and accessible, detailed rules could make it easier for patients and providers to find out what requires prior authorization.
  • Advance notice could give providers time to learn about changes before they take effect.
  • Annual review and evidence-based criteria could help keep prior authorization decisions tied to current standards.
  • An exemption based on a provider’s approval record could reduce repeated requests for items or services that a plan regularly approves.

Case against#

  • The bill leaves key parts of the exemption system to future rules, so its reach and practical effect would depend on later decisions by the commissioner.
  • Website, notice, and review-criteria duties could add costs for plans, but the available material gives no estimate.
  • The bill requires detailed information online, but does not set a complaint process or penalties if a plan fails to provide it.
  • The restrictions on denying claims for associated supplies or services could be difficult to apply in some cases; the bill does not explain how disputes would be resolved.