Both chambers of the North Carolina General Assembly are pushing for healthcare reforms to provide price transparency and authorization efficiency for patients across the state, but questions remain about whether the House and Senate will unite in their proposals to approve health reform legislation during the 2025 session.
The Care First Act aims to eliminate red tape that causes delays in the authorization process that patients must endure in order to receive treatment. House Bill 434 requires timely decisions so that patients and doctors are not left wondering for weeks or months if the patient will receive the needed authorization for treatment coverage.
The House proposal aims to reform the broken prior authorization process in North Carolina’s healthcare system, which has become a major barrier for doctors and patients seeking timely care. During a recent press conference, the bill’s sponsors and supporters from the medical community emphasized the need to restore doctors’ authority in making medical decisions for their patients without unnecessary delays from insurance companies.
Representative Grant Campbell, R-Cabarrus, a practicing physician, highlighted that physicians currently spend an average of 13 hours per week navigating prior authorizations, which leads to delays and negatively impacts patient care. He shared a personal example of a six-week delay in surgery for a patient due to repeated authorization hindrances. Campbell pointed out that physicians sometimes have to appeal to out-of-field non-specialists, such as psychiatrists, for approval on treatments that require specialized knowledge in a different area of medicine.
“On one side, you have the doctor and the patient who have easily known each other for years,” explained Campbell. “That same doctor has examined them, discussed their options, looked at their testing; and on the other side, you have someone sitting in a cubicle in a corporate office that may be a physician, may not be a physician, may be in your specialty, may not be in your specialty, may be seeing patients anymore, and may not be seeing patients. The parade of people that are trying to interfere with the relationship with the patient and their physician has got to stop, and this is one of the great first steps to do that.”
The bill, supported by various medical organizations such as the North Carolina Medical Society and the NC Health Care Association, aims to streamline the authorization process. It also requires health insurers to consult with the doctors prior to a denial, in addition to setting time frames and minimum clinical standards.
The House effort comes one day after senators introduced two bills targeting health care, which will be merged together during the committee process. Senate Bill 316, Lower Healthcare Costs, would help North Carolinians understand the costs and fees associated with their healthcare services by requiring disclosures for billable items. The price transparency would incentivize customers to shop around, say bill sponsors.
The legislation takes other steps to reduce costs as well, such as tasking the state auditor with reviewing facility prices, deregulation to allow more dentists to practice more freely, and eliminating Certificate of Need review for inpatient rehab.
Senate Bill 315, More Transparency/Efficiency in Utilization Reviews, proposes reforms to prior authorization practices to keep costs down and ensure timely care. The bill requires urgent health care services to be reviewed in 24 hours or less, codifies the appeals process, and requires that any doctor conducting a review be actively licensed in that specialty for at least three consecutive years, according to a press release.
“In order to make the best decisions for their care, patients need to have all of the information about their procedure at their fingertips,” said bill sponsor Sen. Amy Galey, R-Alamance. “Shedding light on the true costs of healthcare is good for patients and providers. These proposals will provide much-needed transparency for North Carolinians when they’re making decisions about their health.”
The bills will be heard in the Senate Health Care Committee on Wednesday. While similar prior authorization legislation passed the House unanimously in 2023, the bill stalled in the Senate.
“We would like to applaud the efforts by both the House and Senate leadership to bring these issues to the forefront,” said a spokesperson for Blue Cross Blue Shield North Carolina. “We support their efforts to work with stakeholders to hold everyone accountable for the costs and access to health care. We appreciate the efforts to respond to North Carolinians’ frustrations with the health care system. We are committed to keeping health care affordable and look forward to working with anyone who shares that goal.”
Rep. Timothy Reeder, R-Pitt, expressed optimism that the Senate has acknowledged the issue of prior authorization in healthcare, but he also noted that the House bill includes several key provisions absent in the Senate’s version, such as requirements for insurers to disclose authorization criteria, a shorter processing time, and a mandate for peer reviewers to be licensed in North Carolina.
“There’s a number of things that I’m hopeful that the Senate will consider as we debate both bills and move them forward,” said Reeder. “But I just really am happy and thankful that the Senate acknowledges that this is an issue that we need to deal with.”