SPONSOR: Stinnett
COMMITTEE ACTION: Voted "Do Pass" by the Standing Committee on Insurance by a vote of 11 to 1. Voted "Do Pass" by the Standing Committee on Rules- Administrative by a vote of 10 to 0.
This bill provides that a health carrier or utilization review entity cannot require health care providers to obtain prior authorization for health care services, except under certain circumstances.
Prior authorization is not required unless a determination is made that less than 90% of prior authorization requests submitted by the health care provider in the previous evaluation period, as defined in the bill, were or would have been approved.
The bill establishes separate thresholds for requiring prior authorization for individual health care services or requiring prior authorization for all health care services.
The bill specifies requirements for notifying the provider of determinations in the bill, requires carriers and utilization review entities to maintain an online portal giving providers access to certain information, and provides that prior authorizations may be required beginning 25 business days after notice to the provider until the end of the evaluation period. Failure to notify providers of a determination as required in the bill will constitute prior authorization of the applicable health care services.
Lastly, no health carrier or utilization review entity can deny or reduce payments to a health care provider who had a prior authorization, unless the provider made a knowing and material misrepresentation with the intent to deceive the carrier or utilization review entity, or unless the health care service was not substantially performed.
This bill will not apply to Medicaid, except with regard to a Medicaid managed care organization as defined by law. The bill also does not apply to providers who have not participated in a health benefit plan offered by the carrier for at least one full evaluation period.
This bill should not be construed to authorize providers to provide services outside the scope of their licenses, nor to require health carriers or utilization review entities to pay for care provided outside the scope of a provider's license.
This bill is the same as HB 1976 (2024).
PROPONENTS: Supporters say that the patients are suffering due to long wait times for prior authorization. The bureaucratic hurdles and delays often result in critical treatment being postponed, leading to adverse health outcomes, particularly in rural areas where access to health care is already limited. This bill will also cut down on time physicians are spending on getting authorization for a prescription.
Testifying in person for the bill were Representative Stinnett; Missouri Rural Health Association; Missouri State Orthopaedic Association; Missouri State Medical Association; SSM Health; Missouri Association of Osteopathic Physicians and Surgeons; Missouri Gastroenterology Society; Missouri Society of Eye Physicians and Surgeons; Mercy Healthcare Systems; Missouri Hospital Association; Amy Zguta, Missouri State Medical Association; Brianna Cope, University of Missouri Healthcare; Hannah Thrower, Barnes Jewish Hospital; North Kansas City Hospital; Joanne Loethen; Josephine Glaser MD, FAAFP; Susan Graves, Cox Health; William Bridges, Texas County Memorial Hospital; Golden Valley Memorial Hospital; Hannibal Regional Healthcare System; University Health; Missouri Chapter of The American Academy of Pediatrics; Missouri Psychological Association; Reach Healthcare Foundation, MO Association of Rural Health Clinics, Ranken Jordan, National Association of Social Workers MO Chapter; Mosaic Life Care, Missouri Ambulance Association; Missouri Nurses Association, Missouri Occupational Therapists Association; Kate Lichtenberg, Missouri Academy of Family Physicians; Lara Briseno Kenney ; Matias Hernandez; American College of Obstetricians and Gynecologists, Quest Diagnostics.
OPPONENTS: Those who oppose the bill say that this would allow bad practitioners to use the overall good standing of the hospital to get away with bad service and harmful prescribing. This bill would raise the cost of health insurance. This bill does not have provisions for follow up appointments to see if the treatment was correct and is working.
Testifying in person against the bill were Missouri Health Plan Association; Missouri Insurance Coalition; PCMA; America's Health Insurance Plans, BCBS of Kansas City.
Written testimony has been submitted for this bill. The full written testimony and witnesses testifying online can be found under Testimony on the bill page on the House website.
Statutes affected: