SB 972

Generally, this bill requires and prohibits certain actions related to prior

authorization of physical therapy and other health care services by certain health

plans. Under the bill, every health plan, when requested to reauthorize coverage,

must issue a decision on reauthorization of coverage of a service for which prior

authorization was previously obtained within 48 hours or prior authorization is

assumed to be granted. Health plans are prohibited under the bill from requiring

prior authorization for the first 12 physical therapy visits with no duration of care

limitation or for any nonpharmacologic management of pain provided through care

related to physical therapy provided to individuals with chronic pain for the first 90

days of treatment. The bill requires plans to reference the applicable policy and

include an explanation to the physical therapy service provider and to the covered

individual for an denial of coverage for or reduction in covered physical therapy

services and to compensate physical therapy service providers as specified under the

bill for data entry of clinical information that is required by a utilization review

organization or utilization management organization acting on behalf of a plan. A

plan must also impose copayment and coinsurance amount on covered individuals

for physical therapy services that are equivalent to copayment and coinsurance

amounts imposed for primary care services under the plan.

The bill also requires every utilization review organization and utilization

management organization that is providing review or management on behalf of a

health plan to provide to any licensed health care provider, upon request, all medical

evidence-based policy information that accompanies the algorithms that are used

to manage coverage and to operate and staff peer review activities with

Wisconsin-licensed health care providers holding credentials for the type of service

that is the subject of the review. The bill prohibits utilization review organizations

and utilization management organizations from using claims data as evidence of

outcomes for purposes developing an algorithm to manage coverage or an approval

policy for coverage. Health plans to which the above requirements and prohibitions

apply are private health benefit plans and self-insured governmental health plans.

Additionally, the bill prohibits health care plans and self-insured

governmental health plans from requiring prior authorization for coverage of any

covered health care service that is incidental to a primary covered health care service

and determined by the covered person's physician or other health care provider to be

medically necessary and of any covered urgent health care service as defined in the

bill. Current law prohibits health care plans and self-insured governmental health

plans from requiring prior authorization for coverage of emergency medical services.

This proposal may contain a health insurance mandate requiring a social and

financial impact report under s. 601.423, stats.