Margaret Comstock of Pueblo, who has 34 years of experience in the health/medical field, knows anyone who is caring for a loved one with a chronic health condition is likely to have to battle insurance companies to secure paid-for treatment. One reason, she contends, is that insurance companies and their algorithms too often make medical decisions that patients and their physicians should be making.
“One of the biggest obstacles is the opaque, time-consuming and unpredictable process by which insurance companies approve or deny claims,” Comstock says. So she is pleased to see that Colorado lawmakers are considering a bill this year to improve this process by making needed reforms in the prior authorization process that determines what is covered or not for a patient. If it’s passed, Comstock says House Bill 24-1149 will prevent lapses in care caused by withheld prior authorization and make the process more transparent. “The prior authorization process is unnecessarily burdensome and complicated,” says Comstock, “causing delays in care and taking important health decisions away from physicians and patients. This can have a huge impact on our health and our lives.”
Comstock recounts her own personal experience in which, after getting new insurance coverage due to a job change, she found that one of two medications she had been taking for years to treat her diabetes was suddenly denied coverage. What happened next? As she tells it, “Despite multiple doctors appealing the claim denial — a highly bureaucratic process that costs time and resources that should be directed toward patient care — the insurance company rejected it.” She was facing a potential new expense of $900 a month, which she could ill afford. The health insurance company had a “solution,” which was to tell her doctor to simply increase the other med she was taking. She fumed: “That’s right — someone working in health care claims, someone with no medical training, told my doctor what to prescribe.”
Prior Authorization” Hassles Not Just a Colorado Issue
Comstock goes on to note that a survey by the American Medical Association found that roughly 20% of physicians said that prior authorization policies have led to a life-threatening event or required intervention to prevent permanent impairment or damage. Also, according to KFF (a health news entity), lower-income adults were disproportionately affected, being three times more likely to see a decline in their health due to insurance issues like prior authorization requirements.
“It’s unacceptable that prior authorization essentially allows insurance carriers to practice medicine,” Comstock argues, “when it’s doctors who have the direct medical knowledge, training and experience as well as the direct contact and conversations with their patients to determine what treatment, procedures and medications are best.” She charges that insurers have a “vested interest” in denying access to care, for fiscal reasons.
What the Colorado Bill Would Do for Prior Authorization” Hassles
HB 24-1149 looks at prior authorization requirements imposed by insurance carriers, private utilization review organizations, and pharmacy benefit managers (PBMs) for certain healthcare services and prescription drug benefits covered under a health benefit plan. The bill would require these carriers, organizations, and PBMs “to adopt a program, in consultation with participating providers, to eliminate or substantially modify prior authorization requirements in a manner that removes administrative burdens on qualified providers and their patients with regard to certain healthcare services, prescription drugs, or related benefits based on specified criteria.” Additionally, the bill would prohibit a carrier or organization from denying a claim for a healthcare procedure under specified circumstances.
As the bill currently reads, starting January 1, 2027, if a healthcare provider submits a prior authorization request through an electronic interface or secure electronic transmission system, the carrier, organization, or PBM would be required to accept and respond to the request through its interface or electronic transmission system. Plus, a carrier or PBM would be prohibited from imposing prior authorization requirements more than once every three years for an FDA-approved chronic maintenance drug that the carrier or PBM has previously approved (except under specified conditions.) The bill would also extend the duration of an approved prior authorization for a healthcare service or prescription drug benefit from 180 days to a calendar year.
Finally, under the bill, carriers would be required to post, on their public-facing websites, specified information regarding the number of prior authorization requests that are approved, denied, and appealed; the number of prior authorization exemptions; and the prior authorization requirements as applied to prescription drug formularies for each health benefit plan the carrier or PBM offers.
Coloradans Urged to Support the Bill Regarding Prior Authorization” Hassles
Comstock insists, “We need to speak out against this profit driven system that puts life-altering medical decisions in the hands of insurance companies and their algorithms. Bureaucracy and red tape should never stand between patients and care they need to remain healthy.” She urges Colorado lawmakers to support House Bill 1149. Colorado citizens in turn can prod their state representatives to do so as well.
