Purpose of the Bill

The bill aims to improve transparency and accountability in the health care system by modifying standards for utilization review processes, specifically concerning wrongful denials of prior authorizations for medical services.

Main Provisions

• Utilization Review Modifications: The bill amends the current law to specify that a utilization review organization must attempt to resolve disagreements with health care providers over service authorization by gathering additional information before issuing a denial.

• Right to Action: It creates a legal pathway for enrollees who are denied prior authorization by these organizations. If the denial deviates from standard medical practices, contradicts the attending health care professional's recommendation, and causes harm, the enrollee has grounds to sue.

• Cause of Action Against Physicians: Enrollees can sue physicians who review and deny their prior authorization requests for medical malpractice if it can be shown that the physician ignored the medical professional's input and relevant information.

• Attorney General Enforcement: The attorney general is empowered to investigate and take legal action against utilization review organizations that do not comply with the regulations.

Significant Changes to Existing Law

• The bill updates utilization review practices by requiring more transparency and setting conditions under which a review organization may be held liable for wrongful denials that cause injury.

• It strengthens legal recourse for individuals to contest wrongful denials and emphasizes the obligation of reviewing organizations to heed medical professional recommendations.

Relevant Terms

wrongful denial, prior authorization, utilization review organization, cause of action, medical malpractice, attorney general, health care professional, adverse determination, legal liability, enforcement.