Time to file Prior Authorization Complaints with Office of Insurance Commissioner


fotolia_106949987This summer the Office of the Insurance Commissioner (OIC) will be preparing Rules (Washington Administrative Code) for the prior authorization of health care services. Engrossed Second Substitute House Bill 1471 which was passed through the efforts of the Washington State Chiropractic Association (WSCA) and Washington State Chiropractic Trust (WSCT), addresses some aspects of prior authorization and will go into effect January 1, 2017. (Read more about the bill at this link: http://1.usa.gov/20D8IBP)

Washington State Chiropractors and their patients can help guide this policy by making comments to the OIC about the problems associated with prior authorization including the filing of complaints with the state agency (OIC) whether on your own or through your patients.

Many of you have been providing comment and anecdotes to the WSCA directly and we encourage you to continue to do so. This is great and we can use the detail in our meetings with legislators and the OIC. In addition to reporting these issues to the WSCA, we need you and your patients to make complaints to the Office of the Insurance Commissioner directly! The link is: http://1.usa.gov/1WY4Ey5

You should:

  1. Write a brief report outlining the patient’s condition, treatment goals, recommendations, complications and consequences of inadequate care; and
  1. Explain that the insurer or its contracted entity (such as Evicore) is denying or delaying benefits that the patient has purchased. Their limits and denials of care cause the patient additional risk of poor health outcomes; and
  1. The insurer or its contracted entity are not using individual clinical information as their basis for authorization or denying care; and
  1. The online system for filing prior authorization requests are inadequate and only allow for one patient diagnosis, which is unrealistic and not clinical. They appear to be computer generated!
  1. When filing complaints REDACT all patient identifying information unless your patient has given you written permission to file the complaint on their behalf.
  1. Be clear in your complaint — if you know that there is a violation of law or rule, make that citation known! It does not require a citation, but if you KNOW there is one, use it to help support your claim.

Example: Issuer (name the insurance company) required my patient to obtain a referral for chiropractic care- RCW 48.43.510 (5) says:  “Each carrier shall provide enrollees with direct access to the participating chiropractor of the enrollee’s choice for covered chiropractic health care without the necessity of prior referral. Nothing in this subsection shall prevent carriers from restricting enrollees to seeing only providers who have signed participating provider agreements or from utilizing other managed care and cost containment techniques and processes. For purposes of this subsection, “covered chiropractic health care” means covered benefits and limitations related to chiropractic health services as stated in the plan’s medical coverage agreement, with the exception of any provisions related to prior referral for services.”

  1. Continue to copy the WSCA on your complaints! Email Lori Grass at LGrassi@chirohealth.org or mail to the WSCA, Attn: Lori Grassi, 21400 International Blvd., Ste. 207, SeaTac, WA 98198

Prior Authorization of health care services is interrupting both the doctor-patient relationship and medically necessary care. There are still issues that need to be addressed regarding prior authorization of health care services and your comments on the record will support strong policy for the WSCA and WSCT to work on your behalf.

Finally, we need your ongoing support to continue the work of the WSCT. If you are a regular contributor to the WSCT, THANK YOU! If not, I urge you to do so today!

Just click here to make a one-time or recurring donation. Or you can mail your donation to PO Box 2163, Seattle, WA 98111.

Consider a one-time contribution: $1000, $500, $250, $100 OR sign up for monthly credit card withdrawals: $100, $50, $25.

 

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