Part 1: How Would the Prior Authorization Reform Act Increase Transparency?
June 18, 2021
During the Spring Legislative Session in Springfield, the General Assembly unanimously approved the Prior Authorization Reform Act (House Bill 711)! This top ISMS initiative will be sent to Governor Pritzker for signature sometime this month. This new law requires that substantive and important changes be made to insurer prior authorization (PA) practices.
Starting today, Physician Advocate will be taking a deep dive into the components of this important legislation. This week’s focus is transparency.
The current problem: It can be difficult and time consuming to figure out which services need prior authorization and how PA determinations will be made.
How House Bill 711 helps: Increases transparency by requiring payers to make information about PA policies readily available at the point of care.
The Prior Authorization Reform Act would require health insurance issuers to make any current PA requirements and restrictions, including written clinical review criteria, readily accessible and conspicuously posted on their website. The clinical review criteria must be:
- Based on nationally recognized standards (except where Illinois law has its own standards)
- Developed in accordance with current standards of national medical accreditation entities
- Consistent with providing quality care and facilitating access to needed healthcare services
- Evidence based
- Sufficiently flexible to allow deviations from the norm on a case-by-case basis
- Evaluated and updated, if necessary, annually
Health insurance issuers or their contracted utilization review organizations would be required to update their websites with new or amended requirements before implementation, and provide written notice to contracted healthcare professionals at least 60 days prior to implementing the change. Entities using prior authorization would be required to gather statistics related to approvals and denials and make them available on their website.
If you have questions, please contact ISMS Senior Vice President of Legislative Affairs Erin O'Brien by email.
Watch for next week’s topic related to the Prior Authorization Reform Act – timelines for urgent and nonurgent care.