Prior Authorization from Health Insurers
Insurance Law | health insurance | Insurance | Insurance Claims | Washington Law
By Steven J. Anglés
May 23, 2018
Patients and providers in Washington State recently won an important victory against health insurance companies, by reducing a frustrating and time-consuming restriction when accessing needed medical care. This victory is in the form of legislation passed by Washington State’s Senate and House of Representatives in February 2018, signed into law in March 2018, and that takes effect on June 7, 2018. The topic was a hotly contested one in the patient and healthcare communities: prior authorization.
Under Washington law, health insurance companies are allowed to require that healthcare providers obtain authorization prior to treatment bills getting paid. The new law affects a large number of treatment types and loosens the arbitrary guidelines that health insurers, such as Regence and Premera, and their third-party contractors such as eviCore, have used to deny healthcare benefits.
Previously, health insurers were not allowed to require prior authorization for first-time visits to chiropractors, physical therapists, occupational therapists, acupuncturists, massage therapists, speech therapists, and hearing therapists. But after the first visit, prior authorization requirements were fair game. All the health insurer had to do was conclude that additional care wasn’t medically necessary, therapeutically effective, or cost-effective. Care could be denied if it was considered more for “maintenance” than curative. For example, if a patient was referred by her primary care doctor for chiropractic or physical therapy following a trauma he/she might only get his/her first visit paid for and be forced to pay out of pocket for subsequent follow up, even if his/her chiropractor or physical therapist was “in network” with the health insurer, and even if he/she was allowed many more chiropractic or physical therapy visits in a year under the health insurance plan.
Effective June 7, 2018, the Revised Code of Washington (RCW) 48.42.016 will change. Now, under the new law, health insurance companies are not allowed to require prior authorization for the next six consecutive treatment visits.
However, after the six visits, health insurers can again impose the requirement of prior-authorization and deny payment for additional treatment if they or their hired-gun medical reviewers don’t think the treatment should be covered.
There are other provisions from the old law that stand. First, treatment must still “meet the standards of medical necessity.” Second, treatment is still subject to the terms of the patient’s health insurance plan, including number of visits allotted under the plan. Third, the plan can still require a referral or prescription for the therapies listed above. Finally, if a health insurer is going to deny, limit, or terminate a patient’s benefits, they still need to consult with a licensed or certified healthcare service or provider in the same health field as the provider whose care is being challenged.
If you are interested in learning more, we recommend watching a few minutes of the video footage recorded on January 30, 2018, when the bill was first heard in the Washington State Senate.  The passage of the bill was a collaborative effort between a number of different healthcare organizations in Washington acting together for the benefit of their patients. The bills were sponsored by the Physical Therapy Association of Washington and the Washington State Chiropractic Association, and were supported by many other providers and pro-patient organizations.
 This new law started as Senate Bill 6157 and House Bill 2837. Originally, sponsors of the bills asked for as many as 8 visits to be approved before health insurance companies could start restricting more visits by requiring prior authorization.