Montana Looks To Regulate Prior Authorization as Patients, Providers Decry Obstacles to Care

HELENA — When Lou and Lindsay Volpe’s son was diagnosed with a chronic bowel disease at age 11, their health insurer required constant preapproval of drugs and treatments — a process the Volpes say often delayed critical care for their son.

“You subscribe to your insurance policy, you pay into that for years and years and years with the hope that, if you need this service, it will be there for you,” Lou Volpe said. “And finally, when you knock on the door and say, ‘Hey guys, we need some help,’ they just start backpedaling.”

The Volpes, who live in Helena, and their health care providers spent more than 18 months pushing for these approvals from Blue Cross and Blue Shield of Montana — including a four-month wait last year for approval of costly infusions that worked to control their son’s disease where other treatments had failed.

“It just really slowed everything down on his treatment, and I feel like he could have been recovering from this situation a lot sooner,” Lindsay Volpe said.

Now, the Volpes, other patients, and their health care providers are bringing the issue to the 2025 Montana Legislature, saying it’s time Montana joined many other states in limiting how and when insurers can deny drugs or treatments through their preapproval process, known as “prior authorization.”

This month, a Democratic and a Republican lawmaker introduced or were drafting separate bills restricting health insurers’ ability to require prior authorization for certain treatments and medications. A third lawmaker was preparing other measures as well.

Many of the state’s medical providers are behind the effort, saying prior authorization is denying vital care and needlessly sucking up more and more of their time, which they say could be better spent with patients.

“It has increased incredibly in the last couple of decades, to the point that it’s one of the leading causes of burnout for physicians,” said Lauren Wilson, a Missoula pediatrician and past president of the Montana chapter of the American Academy of Pediatrics. “It’s just delaying patient care for no good reason.”

Montana health insurers, however, insist they are authorizing drugs and treatments that are shown to be needed. If their review power is stripped away, costs will continue to increase due to insurance paying for unnecessary treatments, they said.

Blue Cross and Blue Shield of Montana said it doesn’t comment on individual cases, such as the Volpes’, but said it approves the “vast majority” of prior authorization requests. Blue Cross, which insures or manages health insurance for 384,000 people in Montana, also said it regularly audits its prior authorization procedures and is taking steps to speed up the process.

“Prior authorizations are a way to ensure members receive the right care at the right place at the right time, avoiding unnecessary services and helping providers understand coverage before a service is delivered,” the company said in a statement.

Denial of care through insurers’ prior authorization processes has struck a nerve nationwide as well.

In the wake of the December shooting death of UnitedHealthcare CEO Brian Thompson in New York City, customers of the health insurance giant and other consumers took to social media to denounce the industry for denied claims and puny reimbursements.

And since then, one of the nation’s largest health insurers, The Cigna Group, announced it would spend $150 million this year to reform its prior authorization process and related services for patients and health care providers.

In the past two years, multiple states have passed laws restricting prior authorization, according to the American Medical Association, with New Jersey enacting restrictions over New Year’s. The laws, spearheaded by health care providers, generally narrow when and how prior authorization can occur and create stricter timelines for the review.

Legislators in several states, including Indiana, Nebraska, North Dakota, Virginia, and Washington, have introduced prior authorization bills this year.

In Montana, local health insurers aren’t quietly giving in to increased regulation.

They note that state regulation of prior authorization affects only about a fourth of Montanans with health insurance, because large, self-insured plans managed by national health insurers are under federal rules.

State restrictions on prior authorization will increase costs primarily for three in-state insurers, they say — and, eventually, their customers.

“We feel like our job is to say, ‘Is that the best use of money for our membership?’” Jackie Boyle, senior vice president of external affairs for Mountain Health Co-Op, said of prior authorization. “If we approve something, we are doing it for every patient like them.”

Mountain Health, based in Helena, insures 55,000 people in Montana, Idaho, and Wyoming.

Democratic state Rep. Jonathan Karlen of Missoula is sponsoring two bills: one to remove prior authorization for most generic drugs, inhalers, and insulin, and another that says patients can’t be denied a drug when they switch insurers and are waiting for authorization from the new insurer. The second bill also says a procedure or treatment may be denied only by a physician with a matching specialty.

Karlen said insurers are putting up barriers to care to increase their profits and said it’s time to break those barriers down.

“People should be making medical decisions based on what they and their doctors think, not what their insurance company thinks,” he said. “If a doctor says you need a medication, that’s why you have insurance — so you can get that.”

Republican state Rep. Ed Buttrey of Great Falls said he plans to introduce a bill to help kids with chronic bowel diseases, such as the Volpes’ son, imposing a seven-day limit to decide whether to authorize expensive biologic treatments. If insurers don’t meet the deadline, the drug would be automatically approved.

Buttrey’s bill also would eliminate most retroactive denials — when insurers refuse to pay for treatment they’d authorized.

State Sen. Vince Ricci (R-Billings) said he is preparing other bills that may include even stronger language to restrict prior authorization for drugs for various conditions.

Health care providers and patients have heard the rationale of insurers and promises that improvements will be made, but they say nothing has happened and that it’s time for the state to step in.

“When there are no consequences and no teeth to anything, I can complain all I want, but it doesn’t seem to incite change,” said Kim Longcake, the pediatric nurse practitioner who’s treating the Volpes’ son.

Longcake said she and another specialist in her office tracked the time they spent on prior authorization requests in a two-week period.

“Depending on where you want to see me, I’m booking out four to six months,” Longcake said. “If I wasn’t spending 12 hours a week doing prior authorization stuff, it would improve access to care.”

The Volpes said their son, now 13, couldn’t absorb food and didn’t gain any weight for a year and a half while he went through treatments that didn’t work and repeated preauthorization waits, including for his current treatment, which appears to be working.

“What he’s gone through at that age was really excessive, beyond what was needed for treatment, because we couldn’t get the care that he needed,” his mother said. “If we didn’t get switched to this medication, he’d still be doing that.”

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