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Battling insurance companies for necessary medication, new legislation to regulate Prior Authorization and Fail First practices

While COVID-19 has taken up most of our attention, Pennsylvanians still have other diseases. HB 1194 was proposed last November, but has remained in committee.

HARRISBURG, Pa. — Even though COVID-19 has taken most of our attention away from just about everything else, thousands of Pennsylvanians still battle other chronic illnesses and diseases each and every day. Often part of that battle is with their insurance company.

Insurance companies currently, and often, enforce their prior authorization and fail first (aka step therapy) practices.

Prior authorization is the process in which patients and their physician or specialist must convince the insurance company that the patient needs a certain medicine or procedure in order for them to pay out.

Fail first is often enforced where insurance companies have their clients proceed through other medications, often cheaper, they believe will treat a certain illness or disease before working up to the medication a physician or specialist wants to prescribe.

State Representative Steve Mentzer (R-Lancaster) held a virtual press conference Tuesday to discuss what he believes is the need for proposed new legislation. Rep. Mentzer introduced HB 1194 last November to regulate those insurance companies powers in the commonwealth. 

Until now, the bill has been stuck in committee. But as the COVID-19 crisis has put a spotlight on the medical and insurance fields, patients with chronic illnesses and diseases have still needed treatment and feared for the timeliness of their prescriptions, diagnoses and treatment procedures.

"The current pandemic is a perfect example of why we need to ensure providers and patients get care as quickly as possible," Rep. Mentzer said.

"Cancer patients like myself are already fighting for our lives," Faye Parker of Reading, Berks County, said. "We cannot afford to wait on insurers to approve tests or treatments ordered by our doctors." 

Rep. Mentzer said the bill would call for quicker electronic prior authorization access. Often doctors hire extra staff to call and coordinate with insurance companies, or take time out of their own schedules, to convince insurance companies on their treatment process. The bill would also restrict fail first.

"...to ensure fail first protocols are based on clinical guidelines developed by independent experts. It establishes when appropriate to exempt patients from fail first protocols," Rep. Mentzer said.

State Representative Patty Kim (D-Harrisburg) serves on the House Insurance Committee with Rep. Mentzer. While she and many others also want to help patients and health care providers, Rep. Kim says the bill in its current state won't do it. 

"This bill needs more work to make sure insured individuals get the care they are entitled to," Rep. Kim said.

The bill is still in the House Insurance Committee, but is expected to be discussed again in the near future.

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