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Medical Professionals Want Changes To Insurance Pre-Approval Process For Health Care

Healthcare professionals across the state, including the Chief Medical Officer at OSF St. Joseph Medical Center in Bloomington, are hoping to change how insurance goes about approving requests for medical treatment.

Lawmakers want to change how people get insurance company approval before medical treatment. Advocates say the current process harms patients.

It’s a reintroduced bill after the previous one stalled during the pandemic slowdown in legislative work.

The bureaucratic term is "prior authorization." Doctors have to clear certain prescriptions and procedures with insurance companies before they go ahead and help patients.

The bill would force insurers to put information on their websites about prior authorization requirements and restrictions for specific procedures. It also limits how long providers can take to approve or deny a request. A doctor who has knowledge of the issue at stake would also have to review appeals.

Dr. Robert Panton is the president of the Illinois State Medical Society. Panton said similar reforms have already been adopted in four other states: Arkansas, Delaware, Kentucky, and Ohio.

He said prior authorization isn’t a bad idea, or at least it didn’t start out that way.

“The entire concept of prior authorization started as a reasonable concept to help direct care, and to focus care in certain directions,” said Panton. “It's become an extremely onerous tool.”

Panton said current procedures can block healthcare providers from giving patients care they need.

Nicole Robinson is the vice president of patient access with OSF Healthcare. She said there is now no standard on how long it can take to get an authorization.

“No one wants to get a diagnosis of cancer and have your doctor prescribe a treatment plan, and then wait up to two weeks to hear whether or not, you know, your doctor's approved treatment is actually going to be approved by your insurance,” said Robinson. “It just creates waste in the health care system.”

Authorization delays have even led to patients giving up on getting needed treatment, according to Dr. Paul Pedersen, chief medical officer at OSF St. Joseph Medical Center in Bloomington and a former president of the state medical society.

Pedersen said doctors are in an uncomfortable position.

“You have to say ‘I'm sorry, we can't do this yet. It has to be delayed for a period of time,’” said Pedersen. “It's not a pleasant conversation.”

There may be more than just red tape delays in operation. OSF Patient Access head Nicole Robinson said some insurance companies have turned prior authorization into a cost-saving tool.

"Sometimes they will give us an authorization and then later revoke that authorization even after the service or the provider has provided the treatment," said Robinson. "Then we're stuck with trying to figure out what to do with the bill."

That can put the cost on patients who might not be able to afford it.

“We want our patients to spend their time on focusing on their body's healing, not how they're going to pay for a procedure,” said Robinson.

Christopher Manson, OSF’s vice president of government relations, said the reform bill would take out some of the waste in the process.

“This isn’t going to address everything,” said Manson. “What this will allow for is really an opportunity to really get to the point of taking care of the patient and doing it in the most effective and efficient manner.”

Many medical associations across the state support the bill. Robert Panton of the Illinois State Medical Society said both Democrats and Republicans sponsor the bill.

“This is a bipartisan approach,” said Panton. “It's an issue that affects just about everyone or their families or their friends, and … so many people are influenced by this.”

In the McLean County area, state Rep. Dan Caulkins, R-Decatur, is co-sponsoring the bill. Co-sponsors representing the Peoria area include state Sen. Dave Koehler, D-Peoria, Sen. Jehan Gordon-Booth, D-Peoria, Sen. Sally Turner, R-Beason, Rep. Ryan Spain, R-Peoria, and Rep. Keith Sommer, R-Morton. Koehler serves as a chief co-sponsor on the bill.

Panton said the frustration is not limited to patients.

“Virtually every physician in the state has been frustrated, not by the process itself, but by the way the process is working,” said Panton. “It’s inhibiting their ability to get care for their patients.”

Panton said the insurance companies themselves are the biggest obstacle to the changes. But he said those providers aren’t always opposed to these kinds of bills.

“Sometimes when you have fair regulations that apply to all insurance companies, we use the expression it levels the playing field, and it may actually allow them to be more supportive of it,” said Panton.

BlueCross BlueShield of Illinois, one of the state’s biggest health insurance providers, would not comment on the bill. In a statement, the company said it is “committed to working with our community of providers to help ensure that our members have access to benefits for quality, cost-effective health care that is both timely and appropriate.”

The bill passed unanimously out of the House Human Services Committee last month. It has not yet come up for discussion in the Senate.

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Christine Hatfield, a graduate student in University of Illinois Springfield's Public Affairs Reporting program, is WGLT and WCBU's PAR intern for the first half of 2021.