Medical treatments often need to be pre-approved by insurance – what’s known as “prior authorization.” But many doctors and patients complain the process can be burdensome, causes delays and sometimes prevents people from getting necessary care.
A new state law aims to address those issues, by reforming how prior authorizations work in New Hampshire starting next year.
“One of the exciting things that we did in this process was bringing together lots of people, and we found out that this system isn’t working for anybody – including insurers,” said State Rep. David Nagel, one of the bill’s sponsors.
Nagel, who’s also a practicing physician, said he used to request authorization for a procedure and hear back from an insurer the next day. But the process has grown ever-more complex and time-consuming, and now he said he sometimes waits days or weeks for an answer.
That’s one of the issues the new law aims to tackle. It sets deadlines so that insurers have to process prior authorization requests in a timely fashion. That means 72 hours for urgent situations – or sooner, if a patient’s condition requires it – and seven days for non-urgent procedures, as long as the request is submitted electronically.
If insurers miss those deadlines, the procedure is automatically approved.
Nagel said the way it works now, he has to schedule some procedures weeks out, to account for the time they take to get approved.
“If I can make that seven days or less, especially for somebody who’s in a lot of pain, that would be a wonderful thing,” he said.
The law will also require that insurers use qualified medical experts when determining whether a procedure is medically necessary. Nagel said that should ensure that prior authorization decisions are evidence-based.
“In some of the managed care organizations right now, the person who will tell you whether or not your thing is approved won’t even be in your specialty,” he said.
In a 2023 survey by the health policy organization KFF, 16% of insured adults said their insurance had delayed or denied prior approval for a treatment, service or drug in the past year. That rose to 26% among people who sought treatment for mental health conditions during that time frame.
New Hampshire Insurance Commissioner D.J. Bettencourt said prior authorizations play an important role in controlling health care costs and making sure the care patients get is medically necessary. But it was clear reforms were needed, he said, describing the existing process as often inefficient and “clunky.”
“Those are a lot of the calls that we get when we hear about prior authorization is, ‘Hey, I’ve been waiting X amount of time to hear about this prior authorization. What’s going on with it?’ ” he said.
The health insurance industry and other stakeholders had input into the legislation, Nagel said. A representative of insurance industry group AHIP testified in support of the bill’s final version, saying it would preserve the benefits of prior authorization and encourage more providers to submit electronically, while making the process work better for doctors and patients.
The bill, whose main sponsor was Republican state Sen. Denise Ricciardi of Bedford, had bipartisan support. Gov. Chris Sununu signed it last month.
While the new law does not apply to government insurers like Medicare and Medicaid, the federal Centers for Medicare and Medicaid issued new rules in January that will also require 72-hour turnarounds for urgent cases, and seven-day turnarounds for all other prior authorization requests.
This story is a production of the New England News Collaborative. It was originally published by New Hampshire Public Radio.
