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- Colorado Pathologists, CAP Advocate for Prior Authorization Exemption Safeguard
On April 22, the Colorado Society of Clinical Pathologists (CSCP) and the CAP urged the Colorado legislature to amend Senate Bill 78 to insert a statutory safeguard to deter potential adverse claims impacts on pathologists, laboratories, and patients.
The CAP advocates against reimbursement limitation and denial by health insurance carriers to pathologists for health care services based on whether the ordering physician has utilized or failed to utilize a laboratory benefit management program or clinical decision support system.
The Colorado state legislation requires health carriers or private utilization review organizations to offer a health care provider who met a 95% approval rate for prior authorization over the preceding year an exemption from prior authorization, an incentive award, or other programs designed by the carrier that reduces administrative burdens or wait times for patients.
The CSCP and the CAP wrote to the House Health and Insurance Committee to “urge an amendment to ensure when prior authorization requirements are waived under an there will be a statutory protection against an adverse claims impact upon any physician that performs or supervises a service exempted from such prior authorization. Without this statutory protection, pathologists and laboratories can be denied or limited payment for the services subject to prior authorization exemptions. In these cases, patients may be at financial risk for uncovered health care services.” The CSCP and CAP enhanced and modeled the payment safeguard after Texas’s prior authorization gold-carding law enacted in 2021.
The CSCP and the CAP continue to coordinate with the Colorado Medical Society (CMS).