Relates to utilization review program standards and pre-authorization for certain health care services

◆ The sponsor's argument

Why Gustavo Rivera says this is needed

An American Journal of Managed Care 2020 study found that over 90% of patient care providers experienced delays with prior authorization and of those delays, 90% had patients who experienced adverse outcomes due to those delays. An analysis of prior authorization in the Journal of the American College of Cardiology, "Using Appropriate Use Criteria to Address Pre- Authorization," by Robert Shor, MD, FACC notes that health care provid- ers have developed criteria for utilization management to guide physi- cians that continue to be subject to prior authorization policies and denials by plans to ameliorate negative effects on patient care. The measurable and research-based development criteria is intended to better a patient's quality of care and outcomes by allowing a solid model to be in place for health providers to decide whether a specific treatment would be appropriate and beneficial to the patient. This bill would recenter patient-care in the health care model and prioritize better patient outcomes by addressing the potentially harmful extended timelines of utilization and prior authorization reviews employed by insurance companies. To help accomplish this, the bill would remove references in current law to prior authorization timeframes that rely on "business days," allowing for situations in which a patient may have their care delayed because of a weekend. The prior authorization process already creates processing delays and worsened patient outcomes, and this bill takes corrective action to minimize the impact on a patient's ability to access the care they need. Additionally, the bill creates continuity and eliminates duplicative prior authorizations for prescriptions and a course of treatment to make it more likely for an individual to continue care and adhere to the treatment plan ordered by their health care provider without unreason- able delays by their health insurance plan.

This is the sponsor's own case for the bill, quoted from their memorandum. It is not Agora's description of what the bill does.