Healthcare Professionals make Medical Decisions. Not Insurance Companies

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△ Assembly Bill (AB) 1468 attracts acupuncturists’ attention. Image©envato-DragonImages

AB1468 requires an automated authorization system for medical decisions

By Namwook Cho, L.Ac.

Assembly Bill (AB) 1468, introduced by Assembly Member Jordan Cunningham (Republican, 35th district) on February 19, 2021, attracts acupuncturists’ attention.

This bill would prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2022, that provides coverage for a specified service, including chiropractic services, physical or occupational therapy, and acupuncture and traditional medicine, from requiring prior authorization for the initial 12 treatment visits for that service within a new episode of care.

The bill requires a healthcare service plan or health insurer that implements an automated prior authorization system to use evidence-based clinical guidelines to program the system. And the system should be downloaded on the plan’s insurer’s provider internet website.

Many acupuncturists keep an eye on Assembly Bill 1468, which was introduced by Assembly Member Jordan Cunningham (Republican, 35th district) on February 19, 2021.

Current law allows insurers or insurance companies to use the pre-authorization program and limits patient’s right to have healthcare treatment from healthcare professionals.

For many years, an acupuncturist who has been practicing in Cerritos said, “healthcare professionals should make decisions regarding patient care. Whenever I cannot continue to treat a patient due to the patient’s insurance company’s denial of more treatment sessions, I feel seriously frustrated.”

He continued, “I believe insurance companies seriously limit patient’s rights to have quality medical service in a timely and efficient manner. And there have been communication issues regarding the insurance company’s decision. Most of the time, it is not clear to be understood their decision.”

The bill indicates that “existing law makes a willful violation of the act a crime.” The Knox-Keene Health Care Service Plan Act of 1975 provides for the licensure and regulation of health care service plans by the Department of Managed Health Care.

Existing law generally authorizes a health care service plan or health insurer to use prior authorization and other utilization review or utilization management functions, under which a licensed physician or licensed healthcare professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity.

Existing law requires a health care service plan or health insurer, including those plans or insurers that delegate utilization review or utilization management functions to medical groups, independent practice associations, or other contracting providers, to comply with specified requirements and limitations their utilization review or utilization management processes.

This bill would require a healthcare service plan or health insurer that implements an automated prior authorization system to use evidence-based clinical guidelines to program the system and make the algorithms used for the system available for download on the plan’s insurer’s provider internet website. In addition, the bill would require a plan or insurer that implements an automated prior authorization system to ensure that a licensed physician or licensed health care professional makes the decision to deny or modify a request by examining the request specific to the enrollee or insured and does not simply ratify an automated response.

An insurer that implements an automated prior authorization system shall ensure that a licensed physician or a licensed health care professional who is competent to evaluate the specific clinical issues involved in the health care services requested by the provider decides to deny or modify requests for authorization of health care services for an insured for reasons of medical necessity, according to subdivision (e). A licensed physician or licensed health care professional shall consider the insured-specific authorization request and shall not simply ratify an automated response that would result in the denial or modification of the insured-specific authorization request.

This bill would prohibit a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2022, that provides coverage for a specified service, including chiropractic services, physical or occupational therapy, and acupuncture, and traditional medicine, from requiring prior authorization for the initial 12 treatment visits for that service within a new episode of care. In addition, because a willful violation of the bill’s requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program.

California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. In addition, statutory provisions establish procedures for making that reimbursement.

 

 

 

 

 

 

 

 

 

 

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