HARRISBURG – Gov. Tom Wolf signed into a law a measure sponsored by Sen. Kristin Phillips-Hill (R-York) that makes significant reforms to the prior authorization process for medical treatment, as well as changes to step therapy for prescription drug treatment plans.
Under Act 146 of 2022, health care providers and insurers have to adhere to standards and timely feedback for prior authorization approval for medical treatment and procedures. The law applies to all commercial health insurance carriers and Medicaid plans. The bill also provides a path for appeals to step therapy prescription drug treatment plans to best address provider-recommended option for patients.
Delays in the prior authorization process have often been cited as reasons for patients abandoning treatment plans or negative clinical outcomes, according to a recent survey conducted by the American Medical Association. Prior authorization is the process in which health care providers obtain advance approval from insurers for payment or reimbursement before a specific treatment plan or procedure is delivered to the patient.
Step therapy is a form of prior authorization, but it applies to prescription drug treatment plans. Insurers may recommend different drug treatment option(s) to patients in an effort to control costs.
“This law will expedite health care treatment plans and delivery to the majority of Pennsylvanians. Act 146 will improve health care outcomes and strengthen the relationship between patients and their providers. This law marks one of the most significant reforms to health care in our Commonwealth in decades due to the willingness of all stakeholders working through a process that found compromise,” Phillips-Hill said. “However, we did not lose focus on our goal: improving patient outcomes. Act 146 delivers on this shared goal.”
The new law requires insurers to provide timely approval for both non-urgent and emergency health care services to physicians before services and treatment plans are rendered. The bill also creates streamlined guidelines for step therapy for prescription drugs, as well as new options for patients and their medical professionals to obtain exemption to best treat the medical condition of the patient.
Phillips-Hill notes that health care costs increase under current prior authorization, and step therapy delays as patients abandon treatment plans and often resort to seeking emergency care.
“By connecting patients to their proper treatment earlier, we can keep patients out of emergency rooms and reduce health care costs,” she added.
The law takes effect at the beginning of 2024, which allows health care providers and insurers to establish a system for electronic prior authorization requests.