Ohio Prior Authorization Webinar. Moderated by Pam Fields, State Director Advocacy and Access Arthritis Foundation
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1 Ohio Prior Authorization Webinar Moderated by Pam Fields, State Director Advocacy and Access Arthritis Foundation November 17, 2017
2 Questions? Throughout the Webinar, please use the Q&A feature to send us your questions At the end of the webinar we ll address them!
3 SPEAKERS Megan Faust, Esq. Arthritis Foundation Platinum Ambassador JA Parent Tim Maglione Senior Director of Government Affairs Ohio State Medical Association
4 Megan Faust
5 Ohio s New Prior Authorization Law Tim Maglione, JD Senior Director of Government Affairs Ohio State Medical Association
6 Prior Authorization Prior Authorization is a process that requires physician offices to ask permission from a patient s insurance company before performing certain medical procedures or prescribing certain medications. Why is this issue important to patients? For every 1 hour a physician spends with a patient, the physician spends 2 hours on administrative tasks like prior authorization.
7 Legislative Process Senate Bill 129 The Prior Authorization Reform Act Sponsored by Senator Randy Gardner (R- Bowling Green) and Senator Capri Cafaro (D-Hubbard) Supported by over 80 Photos: ohiosenate.gov/
8 Supporters of SB 129 American Medical Association Academy of Medicine of Cincinnati The Academy of Medicine of Cleveland & Northern Ohio The Academy of Medicine of Toledo and Lucas County Akron Children s Hospital Alcohol & Drug Abuse Prevention Assn. of Ohio American Academy of Pain Management American Academy of Pediatrics, Ohio Chapter American Cancer Society American College of Surgeons, Ohio Chapter American Congress of Obstetricians & Gynecologists, Ohio Section American Lung Association in Ohio and Michigan American Society of Clinical Oncology The Arthritis Foundation Buckeye Art Therapy Association Butler County Medical Society Cancer Support Community Central Ohio Cleveland Clinic Cleveland Kidney & Hypertension Consultants Coalition for Healthy Communities Columbus Medical Association CoverMyMeds Drug-Free Action Alliance First Dayton Cancer Care Holzer Health System ID Consultants Kettering Health Network Kunesh Eye Center Lake Health Lorain County Medical Society Mental Health & Addiction Advocacy Coalition MetroHealth System Mount Carmel Health System Multiethnic Advocates for Cultural Competence National Alliance on Mental Illness of Ohio National Association of Social Workers-Ohio Chapter National MS Society National Patient Advocate Foundation North Ohio Heart North East Ohio Regenerative Medicine Ohio Academy of Family Physicians Ohio Association of Child Caring Agencies Ohio Association of Community Health Centers Ohio Association of County Behavioral Health Authorities Ohio Association of Physician Assistants Ohio Association of Rheumatology Ohio Bleeding Disorders Council Ohio Chapter of the American College of Cardiology Ohio Children s Hospital Association Ohio Citizen Advocates for Addiction Recovery Ohio Council for Home Care & Hospice Ohio Council of Behavioral Health & Family Services Providers Ohio Counseling Association Ohio Dental Association Ohio Dermatological Association Ohio Empowerment Coalition Ohio Federation for Children's Mental Health Ohio Foot and Ankle Medical Association Ohio Gastroenterology Society Ohio Hematology Oncology Society Ohio Hospital Association Ohio Ophthalmological Society Ohio Optometric Association Ohio Osteopathic Association Ohio Pharmacy Association Ohio Psychiatric Physicians Association Ohio Psychological Association Ohio State Chiropractic Association Ohio Suicide Prevention Foundation The Ohio State University, Wexner Medical Center OhioHealth Orthopedic ONE Paul F Vanek Jr, MD, Inc. Premier Behavioral Health Services Prevent Blindness, Ohio Affiliate Sisters of Charity Health System Summit County Medical Society TWC Pharmacy and Wellness Centers University Hospitals Universal Health Care Action Network of Ohio
9 Provisions of the Law Effective January 2017
10 Effective Jan For Providers An insurer must make its prior authorization rules available on its website or portal to participating providers, including what specific information or documentation a provider must submit in order for a prior authorization request to be considered complete and Insurer processed must accordingly. also provide a 30-day advance notice of any new prior authorization rules to participating providers. Photo:
11
12 Effective Jan For Patients An insurer must make information about the policies that clearly identify specific services, drugs, or devices for which a prior authorization requirement exists available on its website. Photo:
13 Effective Jan Retroactive denials will be prohibited when, on the date the provider renders the prior approved service: 1. The patient is eligible; 2. The patient s condition hasn t changed; 3. The provider submits an accurate claim that matches the information submitted by the provider in the approved prior authorization request. Photo: medicaloffice.about.com
14 Effective Jan Retrospective review allowed for a claim where a prior authorization was required but not obtained when the service in question meets all of the following: 1. The service is directly related to another service for which a PA has already been obtained and has already been performed; 2. The service was not known to be needed at the time the original prior authorized service was performed; 3. The need for the new service was revealed at the time the original authorized service was performed.
15 Effective Jan Insurers must also allow for a 12-month prior authorization for medications to treat a chronic disease, subject to certain restrictions. Photo: clinicaladvisor.com
16 Effective Jan A 12-month prior authorization is not required if: Medications are prescribed for a non-maintenance condition. Medication has a typical treatment of less than one year. Medication requires an initial trial period to determine effectiveness and tolerability, beyond which a one year, or greater, prior authorization period will be given. Medication where there is medical or scientific evidence that do not support a 12-month prior approval. Medications is a schedule I or II controlled substance or any opioid analgesic or benzodiazepine. Medication is not prescribed by an in-network provider as part of a care management program.
17 Effective Jan For policies issued on or after January 1, 2017, a health insuring corporation may, but is not required to, provide a twelve month approval for a prescription drug that meets either of the following: a) The drug is prescribed or administered to treat a rare medical condition and pursuant to medical or scientific evidence. b) Medications that are controlled substances that are not opioids or benzodiazepines. Rare medical condition means any disease or condition that affects fewer than two hundred thousand individuals in the United States.
18 Provisions of the Law Effective January 2018
19 Effective Jan Insurers must have a web-based system through which to receive prior authorization requests.
20 The Cost of Prior Authorization Insurer cost for manual prior auth: $3.66 Insurer cost for electronic prior auth: $.04 Provider cost for manual prior auth: $7.17 Provider cost for electronic prior auth: $2.47
21 Effective Jan Faster turnaround times for prior authorization requests: For urgent situations, the insurer shall respond and approve or deny the request within 48 hours. For non-urgent situations, the insurer shall respond and Note: approve Included or deny in the the timeframes request are requests for supporting documentation. within 10 calendar days. Photo: military.com
22 Effective Jan Urgent situations are those where a delay in patient care could seriously jeopardize the life, health or safety, of the patient or, in the opinion of the practitioner with knowledge of the patient s condition, a delay would subject the patient to adverse health consequences without the care that is subject of the request. Photo: mtm-inc.net
23 Timeframes
24 Effective Jan More clarity when an insurer responds to a PA request: If the PA is denied, the insurer must provide the specific reason for the denial. Photo: Community Health Plan of Washington
25 Effective Jan Photo: Home Health Care News Note: Included in the timeframes are requests for supporting documentation. Faster turnaround times for prior auth appeals: For urgent care services, appeals must be considered within 48- hours after the insurer receives the appeal; For non-urgent services, appeals must be considered within 10 calendar days after the insurer receives the appeal.
26 Timeframes Appeals
27 Effective Jan All appeals shall be between the health care provider requesting the service and a clinical peer within the insurer s internal utilization review operation. A clinical peer is a provider in the same, or similar, specialty that typically manages the medical condition under review. Photo: American Academy of Orthopaedic Surgeons
28 Effective Jan If the internal appeal does not resolve the disagreement, either the patient or an authorized representative may request an external appeal, which is decided by a neutral, independent medical expert not associated with the insurer.
29 Other Components Will apply broadly to health insuring corporations, sickness and accident insurers as well as the Medicaid managed care plans. * Exempt from law... Self-Insured TPAs, Medicare Advantage
30 Enforcement If you have a problem getting the benefits of Ohio s new prior authorization law, first try to resolve it with the health plan. They may have an internal appeals process. It that doesn t work, you can file a consumer complaint with the Ohio Department of Insurance using one of three options: Visit Follow this link: How to File a Consumer Complaint Contact ODI Consumer Services at
31 Conclusion SB 129 Prior Authorization Transparency Efficiency Fairness
32 Thank you To our coalition partners To arthritis Advocates and Ambassadors who attended Advocacy and Access Days, made legislative visits, testified, wrote letters, sent s and made calls To the bill sponsors Senator Randy Gardner and the former Senator Capri Cafaro To our guest speakers and to the OH State Medical Association who led the Coalition efforts
33 If you have specific questions, please contact: Pam Fields at (513) or
34
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Regence BlueShield: Choice HSA 1500 Coverage Period: 01/01/ /31/2016
Regence BlueShield: Choice HSA 1500 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual & Eligible Family Plan Type:
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family
This is only a summary If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at wwwmvphealthcarecom or by calling 1-888-687-6277 Important
Know Your Parity Rights
Know Your Parity Rights Produced by: Federal Parity 1. What is mental health parity? Mental health parity generally refers to the concept that insurers must offer the same coverage for mental health/substance
CHI Health Coverage Period: 01/01/ /31/2017 Employee Assistance Program
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Plan Type: (EAP) This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in
Important Questions Answers Why this Matters: What is the overall deductible?
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in
HMO Blue $1,000 Deductible
HMO Blue $1,000 Deductible Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: on or after 01/01/2014 Coverage for: Individual and Family Plan Type: HMO This is only
Regence BlueCross BlueShield of Oregon: Preferred Plan A $500 Coverage Period: 01/01/ /31/2017
Regence BlueCross BlueShield of Oregon: Preferred Plan A $500 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2017 12/31/2017 Coverage for: Individual & Eligible
National Guardian Life Insurance Company: Maine College of Art Student Health Insurance Plan Coverage Period: 09/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Regence BlueCross BlueShield of Oregon: Preferred Coverage Period: 07/01/ /31/2016
Regence BlueCross BlueShield of Oregon: Preferred Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 07/01/2016 12/31/2016 Coverage for: Individual & Eligible Family
Tier 1: $0/$0 Tier 2: $500/$1,500 Tier 3:$1,000/$3,000 Does not apply to preventive care. What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by contacting benefits@northside.com or by calling 1-404-851-8393.
You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.careconnect.com or by calling 1-855-706-7545. Important