Purpose of the Bill

The bill aims to modify the standards and procedures for utilization review organizations (UROs) regarding how they handle prior authorizations for healthcare services. It seeks to address wrongful denials of prior authorizations by setting clear standards and creating a pathway for legal accountability.

Main Provisions

• Utilization Review Process: The bill allows UROs to request additional information if there is a significant disagreement with healthcare providers about the necessity of a medical service. Before denying authorization, the reviewing physician must contact the attending healthcare professional for further details.
• Cause of Action: It permits patients (enrollees) who are harmed by a wrongful denial of a prior authorization to sue the URO or the reviewing physician if the denial deviated from accepted medical practices or went against the advice of the patient's healthcare provider.
• Legal Accountability: The bill specifies that a URO can be held liable if there is documentation showing that the organization ignored the professional judgment of the attending healthcare professional and supporting information for authorization requests.
• Attorney General Enforcement: The Minnesota Attorney General is empowered to investigate and take legal action against UROs that violate these standards.

Significant Changes to Existing Law

• Introduces a legal cause of action specifically for wrongful denials of prior authorizations, which was not explicitly outlined before.
• Provides enrollees with the ability to sue physicians involved in the denial process if specific criteria are met.
• Empowers the Attorney General to enforce these standards through investigation and legal action.

Relevant Terms

• Utilization review, prior authorization, URO, denial of healthcare services, adverse determination, medical malpractice, Attorney General enforcement.