Brenner introduces bill to reduce insurance hurdles for accessing rehabilitation and occupational therapy services

Posted: April 14, 2023 | Health Coverage, Insurance and Financial Services, Senator Brenner

AUGUSTA – On Thursday, Sen. Stacy Brenner, D-Scarborough, introduced a bill to limit when insurance companies can require prior authorization for rehabilitation and occupational therapy. LD 1383, “An Act to Regulate Insurance Carrier Prior Authorization Requirements for Physical and Occupational Therapy Services,” was the subject of a public hearing before the Legislature’s Health Coverage, Insurance and Financial Services Committee.

Sen. Stacy Brenner

“Insurance companies will tell you that they require prior authorization to ensure that the services provided are medically necessary. For physical and occupational therapy services, the ‘medical necessity’ review is done on an online platform using an artificial intelligence algorithm that arbitrarily approves only a small number of visits without regard to the patient’s diagnosis, comorbidities or the number of visits required by the treatment plan. This is not a medical necessity review,” said Sen. Brenner, who is also a nurse-midwife. “These algorithms are widely known to be arbitrary and capricious. They are built to approve a smaller number of visits, while requiring more paperwork for each additional request for more visits. This system of prior authorization is threatening the viability of small private practices, and is the reason new therapy practices are staying out of network entirely.”

LD 1383 would prohibit health insurance carriers from requiring prior authorization for the first 12 visits of rehabilitation or habilitation services. The bill would limit the number of times that re-authorization can occur to every six visits or 30 days, whichever is longer, after these 12 visits for the same episode of care. Additionally, insurance carriers would be prohibited from requiring prior authorization for patients who experience chronic pain for the first 90 days after diagnosis and re-authorization every 6 visits or 30 days.

“With these limits, the therapist will spend less time completing administrative functions including submitting evaluations and other documentation to verify the need for services. The time not spent completing the administrative functions will increase the number of clients seen,” said Kimberly David, President of the Maine Occupational Therapy Association, in testimony supporting the bill. “This will have multiple benefits for all involved including additional clients receiving services, reduced wait lists and times, increased revenue that would cover the cost of overhead.”

“Not every patient needs every form of service to get better, but patients suffer unnecessarily and can have negative, more costly outcomes with delayed care,” said Kathleen Forti-Gallant, with the Maine Nurse Practitioner Association, in testimony supporting the bill. “It is also costly for provider or administrative staff time to do prior authorizations and cumbersome online follow-up communication, when we are just asking for standard care to treat our patients properly. It is costly and inconvenient to the patient to go to multiple appointments instead of diagnosing the problem and starting treatment.”

In April 2022, the Office of the Inspector General for the U.S. Department of Health and Human Services published a report on the use of prior authorization by Medicare Advantage Organizations. The Office of the Inspector General indicated that the use of prior authorization frequently caused delays in the beneficiary’s access to medically necessary services and denial of payments to providers for covered services that should have been paid.

LD 1383 faces further action in committee.