Linsi Franklin of Wake County describes her struggles getting her son’s medicine approved at a news conference on insurance company prior authorization. (Photo: Lynn Bonner)
As a young boy was dealing with the physical and psychological challenges that came with his diagnosis of severe Crohn’s disease, his mother had to fight through insurance company prior authorization hurdles to get him the medicine he needed.
Linsi Franklin recounted her battles to have her 9-year-old son’s medicine approved at a news conference introducing a bill that would impose new regulations on insurance companies’ prior authorization practices.
“For weeks, I would spend hours on the phone daily with the insurance company and the pharmacy, trying to push the prior authorization through,” she said. “I am fighting for prior authorization reform in North Carolina because my son, other 10-year-olds, and other families in North Carolina shouldn’t have to.”
The two medical doctors serving in the House, Reps. Timothy Reeder (R-Pitt), and Grant Campbell (R-Cabarrus) are among the bill’s co-sponsors. The NC Medical Society and the NC Healthcare Association are backing the bill. The Healthcare Association represents hospitals, and the Medical Society represents doctors.
“This bill is going to allow physicians to be the ones to make medical decisions for their patients,” Campbell said. “We’re starting to step between the line of people that are trying to elbow their way in between doctors and their patients.”
Peter Daniel, executive director of the NC Association of Health Plans, said in an interview he had not seen the bill before it was published and had not had time to examine all the details.
“On behalf of the association, I can say that we support a balanced and reasonable approach to reforming the prior authorization process, one that ensures patient safety, maintains health care efficacy, and reduces administrative burdens for providers,” he said.
The bill takes aim at frequent criticisms of prior authorization — that decisions take too long and that the doctors insurance companies hire to review cases don’t specialize in the areas they’re called on to evaluate.
The bill sets time limits for insurance companies to notify doctors if the medical necessity of a service is being questioned. Insurance companies would have to make public a list of services requiring reviews.
Patients and their doctors would have to be notified whether a non-emergency service is approved within 48 hours after the insurance company receives all information about it.
Campbell talked about a patient with a “complex ovarian mass” suspected to be malignant whose surgery was delayed six weeks because of insurance company denials.
“The parade of people that are trying to interfere with the relationship with the patient and their physician has got to stop,” he said.
Breast cancer screening bill advances
The legislature is considering a stack of heath care legislation this year.
The House Health Committee on Tuesday approved a bill that would make it easier for people to afford advanced imaging that can better detect breast cancer.
House Bill 297 is aimed at helping people who are at increased risk of breast cancer, have survived breast cancer, or have a breast abnormality, said Rep. Mary Belk (D-Mecklenburg).
Insurance copays can vary widely for the more advanced cancer detection methods, she said.
Under the bill, insurers would have to apply the same cost-sharing requirements no matter what type of breast cancer detection method is used. Insurers would pay the in-network rate for patients who see out-of-network providers.
The House has approved the bill in three previous sessions, Belk said, but it has never gotten out of the Senate. Bill sponsors made a few changes this year to improve its chances, she said.