An Act relative to reducing administrative burden
By Ms. Friedman, a petition (accompanied by bill, Senate, No. 1403) of Cindy F. Friedman, Joanne M. Comerford, Mike Connolly, Adam Gómez and other members of the General Court for legislation relative to reducing administrative burden. Mental Health, Substance Use and Recovery.
Bill Information
Bill Information
- Presenter:
- Cindy F. Friedman
- Status:
- Referred to Senate Committee on Ways and Means
This bill takes a number of approaches to reduce the administrative burdens that many healthcare providers face, including:
-Requires fully-insured commercial insurance carriers to submit to the Division of Insurance (DOI) information relative to what covered items, services and medications are subject to prior authorization requirements and detailed information about the number and percentage of items, services and medications, are approved, denied, approved upon appeal and the amount of time taken for processing and appeals. DOI is directed to share this data with the legislature, the Health Policy Commission (HPC), and the Center for Health Information and Analysis (CHIA).
-Establishes utilization review criteria and prior authorization requirements for the Group Insurance Commission
-Prohibits denial of payment for services based on an administrative or technical defect where the care is otherwise medical necessary, unless a carrier has a reasonable basis supported by specific information that the claim for services was submitted fraudulently.
-Bolsters clinical validity requirements for utilization review criteria, including prior authorizations, and increasing transparency and communication with providers and members regarding changes to a carrier’s utilization review criteria, including new prior authorization.
-Prohibits retrospective denials when authorization has already been approved except where a prior authorization was approved based on fraudulent information.
-Requires carriers to respond to urgent/emergency prior authorization requests within 24 hours and states that a prior authorization request is deemed to be granted if that carrier does not respond to a competed request or request missing information in the statutory time period.
-Creates new patient protections, including:
*Ensuring continuity of care for 90 days for patients stable on treatment who change plans.
*Ensuring continuity of care by requiring prior authorization be valid for the duration of treatment or at least 1 year; says that dosage changes shall not require a new prior authorization.
*In the event of mid-plan year formulary change, requires continuity of coverage for 90 days or the duration of the plan year, whichever is longer.
*Prohibits the unilateral use of prior authorization by a carrier for providers with alternative payment contracts that include downside risk and allows providers to contractually negotiate use of PA.
-Requires carriers to implement and maintain an API in accordance with CFR, FHIR and U.S. HHS guidance and standards, for the electronic and automated processing of prior authorization requests for medical benefits (including drugs covered under the medical benefit), as well as for drugs covered under a prescription benefit.
-Regulates the use of AI in utilization management, including prohibiting discrimination, requiring audits/inspection of AI programs, disclosure of the use of AI, protecting data/patient privacy, and requiring that AI cannot be the sole basis to delay/deny/modify care.
-Requires that an adverse determination of medical necessity (and therefore a denial of a prior authorization) can only be made by physician or licensed health care provider.
-Establishes penalties for carriers that fail to comply with utilization management requirements for prior authorization, step therapy and regulation of medical necessity requirements.
-Requires the DOI to ensure that state prior authorization forms are consistent with forms established by the federal Centers for Medicare and Medicaid Services and consider other national standards pertaining to electronic prior authorization.
-Establishes a task force to study the use of prior authorization and its impact and make recommendations to simplify and standardize prior authorization. Directs the DOI to consider the recommendations of the task force in developing and implementing rules and regulations to simplify prior authorization standards and processes.
* The bill summary was created by the Primary Sponsor of the bill; no committee of the General Court certifies the accuracy of its contents.
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