March 10, 2022

States Advance Prior Authorization Bills, Washington Passes Out-Of-Network Bill

Several states refer bills on prior authorization to committees. The Washington legislature passes a bill aligning out-of-network provisions with the federal law. Georgia, Louisiana and Tennessee consider bills expanding the scope of practice of physical therapists, physician assistants (PAs) and advanced practice registered nurses (APRNs).

Breast Cancer Screening

In Tennessee, Senate Bill (SB) 2771 passed the Senate Standing Committee on Commerce and Labor. If enacted, the bill would require carriers that provide coverage to enrollees 35 years of age or older to cover annual breast screening by all forms of low-dose mammography, including breast tomosynthesis. Additionally, carriers that cover screening mammograms would be required to provide coverage for diagnostic imaging and supplemental breast screening, including breast magnetic resonance imaging (MRI) or breast ultrasound. Its House companion bill, House Bill (HB) 2544 will be heard before the House Subcommittee on Insurance.

The Tennessee Radiological Society supports the bills and worked with the bill sponsors to draft its language.

Prior Authorization

In Colorado, SB22-078 passed the Senate and was referred to the House Health and Insurance Committee. If enacted, the bill would require a carrier and/or a private utilization organization to offer a provider with at least a 95% approval rate of prior authorization requests over the prior 12 months an alternative to prior authorization requirements. These alternatives could include an exemption from the requirements, incentive awards or other innovative programs to reward provider compliance

In Kentucky, HB 343 was referred to the House Committee on Health and Family Services. If enacted, the bill would prohibit an insurer or its private review agent from requiring a healthcare provider to obtain prior authorization for a particular healthcare service if the insurer or private review agent has approved at least 90% of prior authorizations for a given healthcare service.

In Indiana, HB 1271 failed in the House Committee on Financial Institutions and Insurance. The bill would have addressed healthcare prior authorization.

The Indiana Radiological Society had monitored the bill.

In Mississippi, HB 866 failed in the House Public Health and Human Services Committee. The bill would have restricted a health maintenance organization (HMO) or a carrier that uses a preauthorization process for healthcare services from requiring a physician or provider to obtain preauthorization for a particular healthcare service if the HMO or carrier previously approved at least 90% of prior authorizations for the healthcare services.

In Oklahoma, SB 1409 failed in the Senate Committee on Retirement and Insurance. If enacted, the bill would have required a health benefit plan to exempt a physician or provider from obtaining preauthorization for any healthcare service if the procedure is medically necessary and the health benefit plan has approved at least 90% of prior authorization requests.

The Oklahoma Radiological Society had monitored the bill.

Scope of Practice

In Georgia, HB 1514 was introduced in the House. The bill sponsors seek to permit physical therapists to order diagnostic imaging and ultrasound. Diagnostic imaging would include MRI, computed tomography scanning, positron emission tomography scanning and positron emission tomography/computed tomography, but would not include X-rays, fluoroscopy or ultrasound.

The Georgia Radiological Society opposes the measure.

In Louisiana, SB 158 was introduced and referred to the Committee on Health and Welfare. Bill sponsors seek to change the practice agreement between a PA and physician to a collaborative agreement. PAs would also be permitted to order and interpret diagnostic tests.

In Tennessee, HB 184 will be considered by the Health Subcommittee. If enacted, the bill would permit APRNs to initiate a therapeutic regimen that includes ordering diagnostic services.

The Tennessee Radiological Society opposes the bill.

Out-Of-Network Billing

In Tennessee, HB 2 will be heard before the House Insurance Subcommittee. The bill would require the state insurance commissioner to establish an independent dispute resolution process to resolve disputes regarding bills for out-of-network emergency services.

In determining the appropriate amount to pay for a healthcare service, an independent dispute resolution entity would not consider:

  • Any benchmarking database that includes Medicare or Medicaid reimbursement rates.
  • Medicare or Medicaid reimbursement rates.

When determining a reasonable fee for the services rendered, the independent dispute resolution entity would select either the health carrier payment or the out-of-network facility-based physician's fee. The bill also addresses disputes involving an enrollee.

The Tennessee Radiological Society is monitoring the bill.

In Washington, HB 1688 passed the Washington legislature. If enacted, the bill would align state law with the federal No Surprises Act and address coverage of treatment for emergency conditions. The bill would allow the carrier, after evidence of a good faith effort to contract with a provider group, to enter into an alternative access direct request (AADR) whereby a provider is reimbursed at billed charges for a term of up to three months. At the end of three months, the carrier can file a request to amend the AADR to allow provider reimbursement for the duration of the AADR established by the state arbitration process, which is based upon a commercially reasonable rate. The governor has until April 2 to act on the legislation.

The Washington Radiological Society is neutral on the bill.

For more information about these bills or any other state legislative issue, contact Tina Getachew, Government Affairs Specialist.

The American College of Radiology® (ACR®) has partnered with Fiscal Note, a legislation and regulation tracking service, to provide continuous, comprehensive updates on radiology and healthcare related legislation. Members can opt in for Fiscal Note reports by contacting Eugenia Brandt, Director of State Government Affairs. To stay current on state legislative developments relevant to radiology, view the ACR policy map.