Massachusetts Medical Society: Testimony in Support of An Act Providing Access to Patient Protection Services for Masshealth Consumers and An Act Administering National Standards to Medicaid Medical Necessity Reviews

Testimony in Support of An Act Providing Access to Patient Protection Services for Masshealth Consumers and An Act Administering National Standards to Medicaid Medical Necessity Reviews

The Massachusetts Medical Society wishes to be recorded in support of Senate bill 692, legislation that will provide MassHealth consumers access to patient protection services afforded by sections 12 through 14 of chapter 176O of the general laws.

Senate bill 692 would extend health insurance consumer protections contained in chapter 176O that are not currently available to MassHealth consumers.  These protections include utilization reviews, formal internal grievance processes, and review panels for filed complaints.  Expanding these protections to cover MassHealth members will help to reduce administrative costs by setting expedited timelines for utilization reviews, clarifying bases for adverse determinations, and freeing physicians from excessive administrative burden caused by the complicated prior authorization processes.  Additionally, patients would receive greater protections regarding adverse determinations through the use of an expedited resolution policy and a review panel established by the Office of Patient Protection.

Adopting these protections, already provided to consumers of private insurance by the Massachusetts Patient’s Bill of Rights, would decrease disparities in health care by ensuring parity in access to the aforementioned benefits for MassHealth patients and the physicians who treat them.

The Medical Society also wishes to be recorded in support of H.1157/S.666, which are identical bills to provide national standards to Medicaid medical necessity review.

Like the bill mentioned above, these bills will bring MassHealth into line with more generally applicable standards for the benefit of patients.  MassHealth does not currently provide detailed explanations for adverse determinations made by MassHealth for coverage of services.  Moreover, clinical reviewers in MassHealth case reviews are not necessarily clinicians of the same specialty and do not necessarily follow national guidelines. Administering national utilization review standards for MassHealth and requiring prompt, specific adverse determination information to be provided to both the patient and the provider helps to minimize administrative costs and improve patient outcomes by mandating a timeline for reconsideration of adverse determinations and requiring the specification of alternative treatment options, if any are available.  These requirements will afford physicians the opportunity to better update their clinical practices based on local and national standards of care and to streamline operational systems in order to deliver quality care to their patients in a more efficient manner.

Additionally, these bills would help to address the issue of “administrative complexity,” which the Health Policy Commission has identified as an area of explicit focus.  Members of the Health Policy Commission’s Advisory Council were surveyed regarding numerous types of administrative complexity and specifically ranked prior authorizations as one of two areas of high priority concern.  These bills help to address issues of administrative complexity by streamlining and explicating more precise timelines for these administrative procedures.

The Medical Society appreciates this opportunity to be heard regarding these bills and recommends favorable reporting on H.1963/S.692 and H.1157/S.666.

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