By Autumn Shelton, West Virginia Press Association
CHARLESTON, W.Va. – On day two of the August legislative interim meetings, the Joint Standing Committee on Insurance and PEIA met to hear a couple of presentations on the state’s prior authorization law and its new electronic portal use requirement, which became effective on July 1.
Erin Hunter, deputy insurance commissioner and general counsel for the West Virginia Offices of the Insurance Commissioner, was the first to speak.
According to Hunter, prior authorization is “getting advance approval from an insurance company for a procedure or maybe a drug or a service that your healthcare provider has ordered.”
Hunter explained that the main goal of the state’s prior authorization law was to “promote and require the use of electronic prior authorizations among healthcare practitioners and health insurers,” adding that electronic prior authorizations “reduce administrative burden for healthcare practitioners and bundles items together for an “episode of care,” defined as a specific medical condition that is managed by a healthcare provider and performed at the same site of service, excluding out-of-network care.
Hunter said that the state’s legislature “dipped its toes” in prior authorization legislation in 2019 with House Bill 2351.
In 2023, legislators updated the law (Senate Bill 267) to mandate that providers use an electronic portal to submit prior authorization requests by July 1 of this year, Hunter stated.
“It continued the requirement for episode of care based electronic prior authorizations,” Hunter said. “It also required portal addresses be located on insurance cards as well as web pages, it tightened the review and response timeline for insurance companies from what was in the 2019 law, and it loosened the standards for healthcare practitioners to qualify for the gold card exemption program. The three month mandatory carryover for prior authorizations was also continued as well as the prohibition on prior authorizations for any drugs for a period of three days at inpatient discharge, provided the drug did not cost over $5,000 per day.”
The 2023 update also mandated that health insurers provide quarterly reporting to the insurance commissioner and the DHHR inspector general and established civil penalties for violations, up to $10,000 per violation, according to Hunter.
“We have worked diligently, I believe, with a lot of stakeholders over the last year to get this implemented with provider associations, with the carriers, and we want to continue to do that to assist insurers and provide education wherever possible,” Hunter concluded.
Next to speak was Ben Beakes, executive director of the West Virginia Association of Health Plans, whose members include managed care organizations (MCOs) who manage the state’s Medicaid program.
According to Beakes, it’s difficult to change how business transactions are conducted in the medical industry.
“There are a lot of systems in place that providers are used to, that payers are used to, that patients are used to, the state is used to, so there has been a lot of change over the last few years,” Beakes said.
Beakes explained that in 2023, the state’s legislature wanted the healthcare industry to enter into the 21st century by requiring prior authorizations through an electronic portal.
“The MCOs at the time all had portals – that wasn’t the issue,” Beakes said, noting that only 26 percent of the authorizations were being submitted through the portal. In 2023, there were a total of 166,000 prior authorizations received.
“Commercial providers had a little bit more at 38 percent,” Beakes added. “This is a red flag for us. We knew what the legislature wanted, but that’s a big change.”
Beakes continued that education became important, and healthcare associations were the first step in implementation of the electronic portal, and an online training session was held for any Medicaid provider who wished to attend.
“We had 318 provider groups register for that online training,” Beakes said.
At first, Beakes explained the providers didn’t understand why they were being forced to change.
“There was a lot of fear on their part, a lot of panic,” Beakes stated. “I believe our efforts with the hospital association, with other associations, and that online training really reduced a lot of that panic. It’s been positive since we rolled it out. We haven’t had any major glitches. The biggest misunderstanding was the universal application across all insurance. Because we took the lead, our association the Medicaid MCOs took the lead, there was a misunderstanding from providers that this was just applicable to the Medicaid program and so they didn’t realize that this was all insurance.”
Beakes concluded that his association, as well as others, will continue to work to provide training and educational resources.
The next meeting of the Joint Standing Committee on Insurance and PEIA will take place in October.
