An Act to amend 632.85 (title) and 632.85 (3); to create 632.85 (1) (d) and 632.851 of the statutes; Relating to: prior authorization for coverage of physical therapy, occupational therapy, speech therapy, chiropractic services, and other services under health plans.
SB373 would change Wisconsin health insurance prior-authorization rules for certain rehabilitative and related services. The bill bars health plans from requiring prior authorization for the first 12 visits of physical therapy, occupational therapy, speech therapy, or chiropractic care in an episode of care, and it separately bars prior authorization for the first 90 days of nonpharmacologic pain management using physical therapy, occupational therapy, or chiropractic care for people with chronic pain, subject to a twice-per-week limit per service. It also defines “urgent health care service” and extends the existing prior-authorization prohibition to urgent services and to medically necessary services incidental to a covered surgical service.
The bill also adds administrative and disclosure requirements for health plans that cover these services. Plans would have to explain denials or reductions in coverage to both the provider and the covered person, use copayments and coinsurance for these services that are equivalent to primary care cost-sharing, and decide reauthorization requests within three business days. If the plan misses that deadline, reauthorization is deemed approved. These requirements apply to private health benefit plans and self-insured governmental health plans.
SB373 further regulates utilization review and utilization management organizations acting for health plans. Those entities would have to provide licensed providers, on request, the medical evidence-based policy information underlying the algorithms used to manage coverage, and they would be prohibited from using claims data as evidence of outcomes when developing coverage algorithms or approval policies. Peer review activities would have to be staffed by Wisconsin-licensed providers with credentials appropriate to the service under review.
The overall sentiment reflected by the bill text and sponsorship is consumer- and provider-friendly, with the measure aimed at reducing administrative barriers to care and speeding access to therapy and chiropractic services. The bill was introduced with a broad bipartisan-looking list of cosponsors, but there is no recorded committee transcript or vote history in the provided materials to show debate or amendments. The bill ultimately failed to pass pursuant to Senate Joint Resolution 1, so it did not become law.
The main points of contention likely center on whether the bill would meaningfully improve access to care or instead limit health plans’ ability to manage utilization and control costs. Insurers and utilization review organizations would likely object to the automatic approval feature, the limits on prior authorization, and the restrictions on algorithm use and claims-data reliance, while supporters would likely emphasize reduced delays, greater transparency, and easier access to therapy and pain-management services.
If enacted, SB373 would amend Wisconsin insurance law governing prior authorization under s. 632.85 and create a new s. 632.851 to impose specific coverage rules for physical therapy, occupational therapy, speech therapy, chiropractic services, urgent health care services, and certain services incidental to surgery. It would affect private health benefit plans and self-insured governmental health plans, requiring changes to utilization review practices, provider communications, cost-sharing structures, and turnaround times for reauthorization decisions. It would also constrain how utilization review and utilization management organizations develop and apply coverage algorithms and conduct peer review.
The bill appears to have been framed as a patient-access and provider-transparency measure, with support implied by its multiple cosponsors and its focus on limiting prior authorization delays. At the same time, the absence of recorded committee discussion or votes means there is no direct evidence in the provided materials of formal opposition or negotiated compromise. Its final failure to pass indicates it did not secure sufficient legislative support to advance.
Likely areas of contention include the reduction of prior authorization requirements, the deemed-approval rule after three business days, and the prohibition on using claims data as evidence of outcomes for coverage algorithms. Health plans and utilization review entities would likely argue these provisions interfere with medical management and cost containment, while supporters would argue they prevent unnecessary delays and opaque denials. Another possible point of dispute is the requirement that peer review be conducted by Wisconsin-licensed providers with relevant credentials, which could be viewed as improving clinical quality or as limiting flexibility for plan administration.