2018 State Legislative Conference October 25 - 27, 2018 Ft. Lauderdale, FL

1. OAFP Road to Prior
Authorization Legislation
Sarah Sams, MD, FAAFP
sarahsams@Hotmail.com
614-329-5878

2. Our Journey
 November 2015 and May 2016, Testified on SB 129
 SB 129 passed Ohio General Assembly May 25, 2016
 January 2017 Legislation went into effect with additional
provisions January 2018.
 Step Therapy Legislation: Still being debated
SB 243/HB 443 (131st GA) Testified 2016
SB 56/HB 72 (132nd GA), Testified 2017, 2018,
Business community claims this is insurance mandate

3. The Rules
 Insurers must disclose all PA rules to providers including specific
information or documentation that Physician must submit for the
PA request to be considered complete
 Insurers must disclose all NEW PA requirements at least 30 days
prior to the effective date of the new requirement.
 Enrollees must receive basic information about which drugs and
services will require prior authorization.
 Insurers must allow for a 12 month PA for medications to treat a
chronic disease under certain circumstances

4. The Rules
 Prohibits retroactive denials when on the date that service
was rendered:
The patient is eligible
The patient’s condition hasn’t changed
Physician submits an accurate claim that matches
information submitted by the physician in the previously
approved PA request

5. The Rules
 Provision allowing retrospective review of a claim where PA is
required but not obtained when the service meets the following:
The service relates to another service for which a PA was
already obtained and has already been performed
The service was not known to be needed at the time the
original PA service was performed
The need for the new service was revealed at the time the
original authorized service was performed

6. Additional Rules as of 2018
 Insurers must have web-based system through which to
receive PA requests
 Mandatory Faster turn around times for original PA
 Mandatory Faster turn around times for PA appeals
 Insurers required to respond to PA requests with more clarity
 Complaints to be filed with Ohio Dept. of Insurance for
investigation

7. Susan K. Fidler, MD
Chair,
PAFP Government and Practice Advocacy Committee

8. “A growing frustration: Asking insurers’ permission for medical treatments”
Article, Pittsburg Post-Gazette. Published: April 30, 2018.

9. PAFP Member Email. Subject: “Sound off on prior authorizations”
Sent to 5500+ members on January 30, 2018

10. PAFP Member Survey Results

11. PAFP media release. Issued February 20, 2018

12. House Bill No. 1293

13. MAINTENANCE
OF CERTIFICATION
S.B.
1148

14. S.B. 1148 Background
Texas Academy of Family Physicians | 14
Bill carried by
Senator Dawn
Buckingham
Republican
Ophthalmologist
and
Representative
Greg Bonnen
Republican
Neurosurgeon

15. S.B. 1148 Background
Texas Academy of Family Physicians | 15
Bill took effect January 1, 2018

16. S.B. 1148 Background
Texas Academy of Family Physicians | 16
Prevents the Texas
Medical Board from using
MOC as a requirement for
doctors to obtain or
renew a medical license

17. S.B. 1148 Background
Texas Academy of Family Physicians | 17
In most instances, it bars hospitals and
health plans from discriminating against
or differentiating between physicians
based on the MOC status

18. ANY QUESTIONS?