In his biennial state budget address to the Wisconsin Legislature, Governor Evers has proposed a number of provisions aimed at cracking down on health insurance companies who have high rates of denying or restricting patient care. The Governor is proposing a number of solutions including audits of companies with high denial rates, limits on the use of pre authorizations, greater transparency of denied claims and a new office within WI OCI to handle consumer health care complaints. The Governor’s budget address marks the official start of the 2025-2026 state budget process which happens in the odd year of the two year session of the Wisconsin Legislature.
The Governor included his health insurance reform ideas as part of the Wisconsin Office of the Commissioner of Insurance’s budget package. Here is what he is specifically proposing within WI OCI.
Health Insurance Claims Denial Audits
The Governor recommends establishing a framework for auditing high rates of health insurance claims denials among insurers offering plans in the state over which the office has regulatory authority. To improve the coverage of health insurance plans, the office would audit insurers with claims denial rates above a certain percentage, as determined by the office, and require corrective action plans based on the audit findings. The Governor also recommends granting the office the ability to enforce corrective action plans through fines, forfeitures or other mechanisms to ensure compliance within a certain date of receiving the corrective action plan.
Prior Authorization Exemption Requirements
The Governor recommends establishing a framework to streamline and expedite coverage approvals for medical procedures, allowing insured individuals to receive prompt determination regarding coverage for their care. The office would develop parameters for when services are exempt from requiring prior authorization by a health insurer. Providers who receive prior authorization approvals above a certain rate would be exempt from requiring prior authorization for services provided or recommended to them.
Prior Authorization Transparency
The Governor recommends requiring health insurers to provide consumers with a list of treatments and services covered by health plans offered by the health insurer which require prior authorization.
Public Intervenor Office
The Governor recommends creating a Public Intervenor Office within the office to provide information and assistance to health insurance consumers to ensure they receive the best possible claim outcomes they are entitled to under their insurance policies. Consumers whose health insurance claims are denied would be assisted with appeals and other legal actions to pursue coverage for health care services.
The GOP controlled Legislature has already announced that it will remove policy proposals like Ever’s health insurance reforms from the state budget.
Last session, the WCA joined with a number of other health care provider groups to support AB 507 which among other things would have prohibited health insurance companies from requiring pre authorization for the first 12 visits. This legislation will likely be reintroduced this session and the WCA will support it.
“The WCA appreciates the Governor’s ideas to help patients access the care they need and require greater accountability from health insurance companies,” said John Murray, WCA Executive Director and CEO.