Central PA Medicine - February 2017 - 23

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Finally, in the 2015-2016 session, HB 182 processes, reform the insurance credentialing
was introduced to permit pharmacists to process, and promote the use of telemedicine
administer flu shots only to children ages seven in Pennsylvania. While these proposals didn't
and older. With a more reasonable starting point make it across the finish line before the General
and the support of the primary care specialties, Assembly concluded the 2015-2016 session, they
PAMED withdrew opposition and worked will be reintroduced in the new year. PAMED
with stakeholders to raise the minimum age to looks forward to building on the progress made
nine and ensure pharmacist notification to the and further advancing these proposals in the
child's primary care provider within 48 hours of 2017-2018 session.
administering the immunization. Recognizing
that on balance there is a benefit to allowing
Many health plans require medical providpharmacists to administer flu shots to minors, ers to obtain prior authorization for certain
PAMED supported the final version of HB procedures or treatments before they can be
182 with these provisions, and it was signed administered. While the process is intended
into law in June 2015.
to minimize overuse of healthcare services,
it often becomes an extremely burdensome
Retroactive denial
process for physicians and their patients due
to a lack of standardization and transparency
For several years, PAMED and a number of in prior authorization requirements. HB 1657,
other stakeholder groups have sought reforms sponsored by Rep. Marguerite Quinn, would
to the current insurance practice of retroactively increase transparency and consistency in prior
denying reimbursements. This session, numerous authorization criteria, establish standards for and
bills were introduced in both the Senate and the reduce the overuse of prior authorization, lessen
House of Representatives to bring fairness to the manual processes and enhance the electronic
retroactive review and reimbursement process exchange of information, develop a standard
between insurers and providers. Ultimately, it prior authorization form, and improve response
was HB 2241, sponsored by Rep. Karen Boback, times for prior authorization determinations.
which was passed by the General Assembly and This legislation, which was introduced and
approved by the Governor on Nov. 4, 2016.
referred to the House Health Committee in
March 2016, would go a long way toward
Now Act 146 of 2016, this new law pro- addressing administrative waste in our health
hibits an insurer from retroactively denying care delivery system, resulting in both cost
reimbursement more than 24 months after the savings and improved access to care.
date the insurer initially paid the health care
provider. An insurer that retroactively denies
The credentialing process for physicians can be
reimbursement to a health care provider will a long and burdensome one, often resulting in
be required to give the health care provider a delays of several months before a hired physician
written statement specifying the basis for the is formally credentialed and can begin seeing
denial. Limited exceptions to the 24-month patients. The bureaucratic and time-consuming
limitation are provided. PAMED supported credentialing process is not only frustrating for
this legislation, which addresses a significant physicians, but also negatively impacts patients,
pain point for many physician practices and who may face limited access or delays in care.
represents a significant improvement from To address these issues, PAMED worked closely
current retroactive review practices.
with Rep. Matt Baker on the introduction of
HB 1663, legislation which would improve the
Priority legislation advanced:
process of physician credentialing in PennsylPrior authorization, insurance
vania by making it timelier and more uniform
credentialing, and telemedicine
across insurers. Specifically, HB 1663 would
require all insurers to use a common application
The 2015-2016 legislative session saw the form, and it would provide for "provisional
successful introduction and advancement on credentialing," an expedited process to issue
several priority issues for PAMED, including credentialing decisions within 30 days. Insurers
legislation to streamline prior authorization would be required to reimburse for services if

they have not approved a completed application
within the 30-day period. However, the bill
would not prevent insurers from rejecting an
application if the situation warrants such an
action. The proposed reforms in HB 1663
would minimize current administrative burdens,
expedite the credentialing process, and sustain
the ability of insurers to have providers within
their networks who are appropriately licensed
and qualified. HB 1663 was introduced this
legislative session and approved by the House
Health Committee on Sept. 21, 2016.
Legislation to promote the development
of and access to telemedicine in Pennsylvania
was also successfully introduced this session.
PAMED's Telehealth Task Force provided
draft bill language. Sen. Elder Vogel introduced
SB 1342 in the Senate and Rep. Marguerite
Quinn introduced identical legislation, HB
2267, in the House. PAMED worked closely
with both bill sponsors to solicit feedback
and the input from a number of key stakeholder groups prior to the bill's introduction,
including HAP, insurance companies, and
several established telemedicine providers.
As introduced, the legislation would define
what telemedicine is and establish guidelines
outlining who can provide telemedicine services,
professional liability coverage, requirements for
evaluation and treatment, and medical record
standards. Additionally, the legislation would
provide clarity that telemedicine services will
be reimbursed by insurance. PAMED strongly
supports the proposal, recognizing that there is
a growing number of services being provided
via telemedicine technologies and a need for
a set of safeguards and standards to support
the appropriate coverage of and payment for
telemedicine services. This bill would address
several barriers and bring clarity to the expanded
use of telemedicine in the Commonwealth.
As we look ahead to the 2017-2018 session,
we have a lot of work to do in order to protect
and advance the practice of medicine in
Pennsylvania. Crucial to PAMED's success,
however, is sustained physician involvement.
When individual physicians speak up and
make their voice heard, organized medicine
is strongest.

Central PA Medicine February 2017 23

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