HELENA, Mont. \u2014 When Lou and Lindsay Volpe\u2019s son was diagnosed with a chronic bowel disease at age 11, their health insurer required constant preapproval of drugs and treatments \u2014 a process the Volpes say often delayed critical care for their son.<\/p>\n
\u201cYou subscribe to your insurance policy, you pay into that for years and years and years with the hope that, if you need this service, it will be there for you,\u201d Lou Volpe said. \u201cAnd finally, when you knock on the door and say, \u2018Hey guys, we need some help,\u2019 they just start backpedaling.\u201d<\/p>\n
The Volpes, who live in Helena, and their health care providers spent more than 18 months pushing for these approvals from Blue Cross and Blue Shield of Montana \u2014 including a four-month wait last year for approval of costly infusions that worked to control their son\u2019s disease where other treatments had failed.<\/p>\n
\u201cIt just really slowed everything down on his treatment, and I feel like he could have been recovering from this situation a lot sooner,\u201d Lindsay Volpe said.<\/p>\n
Now, the Volpes, other patients, and their health care providers are bringing the issue to the 2025 Montana Legislature, saying it\u2019s time Montana joined many other states in limiting how and when insurers can deny drugs or treatments through their preapproval process, known as \u201cprior authorization.\u201d<\/p>\n
This month, a Democratic and a Republican lawmaker introduced or were drafting separate bills restricting health insurers\u2019 ability to require prior authorization for certain treatments and medications. A third lawmaker was preparing other measures as well.<\/p>\n
Many of the state\u2019s medical providers are behind the effort, saying prior authorization<\/a> is denying vital care and needlessly sucking up more and more of their time, which they say could be better spent with patients.<\/p>\n \u201cIt has increased incredibly in the last couple of decades, to the point that it\u2019s one of the leading causes of burnout for physicians,\u201d said Lauren Wilson, a Missoula pediatrician and past president of the Montana chapter of the American Academy of Pediatrics. \u201cIt\u2019s just delaying patient care for no good reason.\u201d<\/p>\n Montana health insurers, however, insist they are authorizing drugs and treatments that are shown to be needed. If their review power is stripped away, costs will continue to increase due to insurance paying for unnecessary treatments, they said.<\/p>\n Blue Cross and Blue Shield of Montana said it doesn\u2019t comment on individual cases, such as the Volpes\u2019, but said it approves the \u201cvast majority\u201d of prior authorization requests. Blue Cross, which insures or manages health insurance for 384,000 people in Montana, also said it regularly audits its prior authorization procedures and is taking steps to speed up the process.<\/p>\n \u201cPrior authorizations are a way to ensure members receive the right care at the right place at the right time, avoiding unnecessary services and helping providers understand coverage before a service is delivered,\u201d the company said in a statement.<\/p>\n Denial of care through insurers\u2019 prior authorization processes has struck a nerve nationwide as well.<\/p>\n In the wake of the December shooting death of UnitedHealthcare CEO Brian Thompson<\/a> in New York City, customers of the health insurance giant and other consumers took to social media to denounce the industry for denied claims and puny reimbursements.<\/p>\n And since then, one of the nation\u2019s largest health insurers, The Cigna Group, announced it would spend<\/a> $150 million this year to reform its prior authorization process and related services for patients and health care providers.<\/p>\n In the past two years, multiple states have passed laws<\/a> restricting prior authorization, according to the American Medical Association, with New Jersey enacting restrictions over New Year\u2019s<\/a>. The laws, spearheaded by health care providers, generally narrow when and how prior authorization can occur and create stricter timelines for the review.<\/p>\n Legislators in several states, including Indiana, Nebraska, North Dakota, Virginia, and Washington, have introduced prior authorization bills this year.<\/p>\n In Montana, local health insurers aren\u2019t quietly giving in to increased regulation.<\/p>\n They note that state regulation of prior authorization affects only about a fourth of Montanans with health insurance, because large, self-insured plans managed by national health insurers are under federal rules.<\/p>\n State restrictions on prior authorization will increase costs primarily for three in-state insurers, they say \u2014 and, eventually, their customers.<\/p>\n \u201cWe feel like our job is to say, \u2018Is that the best use of money for our membership?\u2019\u201d Jackie Boyle, senior vice president of external affairs for Mountain Health Co-Op, said of prior authorization. \u201cIf we approve something, we are doing it for every patient like them.\u201d<\/p>\n Mountain Health, based in Helena, insures 55,000 people in Montana, Idaho, and Wyoming.<\/p>\n Democratic state Rep. Jonathan Karlen of Missoula is sponsoring two bills: one to remove prior authorization<\/a> for most generic drugs, inhalers, and insulin, and another that says patients can\u2019t be denied a drug when they switch insurers and are waiting for authorization from the new insurer. The second bill<\/a> also says a procedure or treatment may be denied only by a physician with a matching specialty.<\/p>\n Karlen said insurers are putting up barriers to care to increase their profits and said it\u2019s time to break those barriers down.<\/p>\n \u201cPeople should be making medical decisions based on what they and their doctors think, not what their insurance company thinks,\u201d he said. \u201cIf a doctor says you need a medication, that\u2019s why you have insurance \u2014 so you can get that.\u201d<\/p>\n Republican state Rep. Ed Buttrey of Great Falls said he plans to introduce a bill to help kids with chronic bowel diseases, such as the Volpes\u2019 son, imposing a seven-day limit to decide whether to authorize expensive biologic treatments. If insurers don\u2019t meet the deadline, the drug would be automatically approved.<\/p>\n Buttrey\u2019s bill also would eliminate most retroactive denials \u2014 when insurers refuse to pay for treatment they\u2019d authorized.<\/p>\n State Sen. Vince Ricci (R-Billings) said he is preparing other bills that may include even stronger language to restrict prior authorization for drugs for various conditions.<\/p>\n Health care providers and patients have heard the rationale of insurers and promises that improvements will be made, but they say nothing has happened and that it\u2019s time for the state to step in.<\/p>\n \u201cWhen there are no consequences and no teeth to anything, I can complain all I want, but it doesn\u2019t seem to incite change,\u201d said Kim Longcake, the pediatric nurse practitioner who\u2019s treating the Volpes\u2019 son.<\/p>\n Longcake said she and another specialist in her office tracked the time they spent on prior authorization requests in a two-week period.<\/p>\n \u201cDepending on where you want to see me, I\u2019m booking out four to six months,\u201d Longcake said. \u201cIf I wasn\u2019t spending 12 hours a week doing prior authorization stuff, it would improve access to care.\u201d<\/p>\n The Volpes said their son, now 13, couldn\u2019t absorb food and didn\u2019t gain any weight for a year and a half while he went through treatments that didn\u2019t work and repeated preauthorization waits, including for his current treatment, which appears to be working.<\/p>\n \u201cWhat he\u2019s gone through at that age was really excessive, beyond what was needed for treatment, because we couldn\u2019t get the care that he needed,\u201d his mother said. \u201cIf we didn\u2019t get switched to this medication, he\u2019d still be doing that.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n