Michigan Reforms Prior Authorization Process to Increase Speed, Transparency

Michigan Gov. Gretchen Whitmer last month signed Public Act 60, which reforms the prior-authorization process for patients and healthcare professionals in the state. The goal of the act, which becomes effective this past June 1, is to make the prior-authorization process faster, more effective, and more transparent. The changes outlined in Public Act 60 apply to healthcare insurers and professionals with commercial insurance policies regulated by the Michigan Department of Insurance & Financial Services.

One of the key reforms of this legislation is the requirement that insurers provide an online option for submitting prior-authorization requests for any benefits, including prescription medications. This digital submission process is expected to make the prior-authorization process more efficient and convenient for both patients and healthcare professionals. Physicians and healthcare professionals must submit prior authorizations electronically, except in cases of technological or electrical failure, which will reduce paperwork and administrative burden.

Under Public Act 60, prior authorization approvals will be valid for 60 days or for as long as is clinically appropriate, whichever is longer. This change is intended to reduce unnecessary delays in patient care and ensure that prior authorizations remain valid for the appropriate duration.

Public Act 60 also includes provisions for urgent and non-urgent prior authorization requests. Urgent requests must now be acted on within 72 hours or are automatically approved. Non-urgent requests must be acted on within nine days, or they are automatically approved. These timelines are expected to expedite the prior-authorization process and ensure that patients receive timely access to necessary medical services.

In cases where a denial of prior authorization is appealed, the appeal must now be reviewed by a licensed physician who is board-certified in the same specialty as the service provided. This change aims to ensure that denials are reviewed by qualified medical professionals who can make informed decisions based on their expertise.

Public Act 60 mandates prior-authorization requirements be based on peer-reviewed clinical review criteria that considers atypical populations, reflects a community standard of care, ensure services are of high quality and publicly accessible, and are evaluated and updated annually. This change aims to promote evidence-based decision-making in the prior authorization process and ensure that patients receive medically necessary care.

To improve transparency, the new law also directs that changes to prior-authorization requirements must be posted online within a specific timeline. This change aims to ensure that healthcare professionals and patients have easy access to up-to-date information about prior-authorization requirements, reducing delays in the process.

In cases where prior authorization is denied, healthcare professionals must now be notified of the reason for denial and given evidence-based criteria. This change aims to improve communication between insurers and healthcare professionals, allowing for a better understanding of the reasons behind denials and facilitating the appeals process.

Finally, Public Act 60 requires insurers to adopt a “gold card” program that promotes the modification of prior-authorization requirements based on healthcare professionals’ adherence to medical and quality guidelines. This change aims to incentivize healthcare professionals to follow evidence-based practices and guidelines, potentially reducing the need for prior authorization in certain cases.