MSDC to DHCF: Fund Prior Authorization February 9, 2024

Written by MSDC Staff


On Thursday, MSDC Advocacy Committee Chair Dr. Klint Peebles testified that the District government needs to fully fund the new prior authorization legislation.

Dr. Peebles testified at the DC Department of Healthcare Finance (DHCF) oversight hearing before the Committee on Health. The annual hearing is an opportunity for the public to share concerns, suggestions, and comments on the department's performance in the previous year.

MSDC used the hearing to draw attention to the inequality in DC's prior auth legislation, now in effect. Due to the bill containing a funding requirement, private insurers are required to comply with the new law but Medicaid providers do not until funding for compliance is included in the DC budget.

Below is the written statement and testimony of Dr. Peebles.

February 8, 2024
Councilmember Vincent Gray Councilmember Christina Henderson
Chair, Committee on Health Equity Chair, Committee on Health
1350 Pennsylvania Ave NW 1350 Pennsylvania Ave NW
Washington, DC 20004 Washington, DC 20004
Dear Chair Henderson and Chair Gray,
The Medical Society of the District of Columbia (MSDC) is the largest medical organization representing metropolitan Washington physicians in the District. We advocate on behalf of all 11,000 plus licensed physicians in the District and seek to make the District the nation’s model for patient care and physician practice.

We applaud Deputy Mayor Wayne Turnage, Medicaid Director Melisa Byrd, and the entire leadership team and staff of the Department of Health Care Finance. We have found their offices to be responsive and communicative. MSDC is also proud to serve on the Medical Care Advisory Committee.

Both of you, and many members of your committees, supported B25-124, the Prior Authorization Reform Amendment Act, when it was introduced. The legislation has now become law but due to a fiscal note the law only applies to private insurance. This creates a health inequality that needs to be rectified, unfortunately through the budget process.

Consider two women patients. Woman #1 goes to her dermatologist and is prescribed a name brand drug for eczema. If she has private insurance and that insurer issued a prior authorization for the prescription, the insurer would (1) need to respond to any appeal of the denial in a set period of time, (2) have licensed physicians reviewing the request and appeal, (3) be required to offer information to help with any appeal, and (4) would not be allowed to make determinations based on cost.

Now consider Woman #2. She goes to the dermatologist but is a DC Medicaid beneficiary. The same prescription may also have a prior authorization, but unlike Woman #1, this person has no support and may be left in limbo waiting to see if her appeal is denied. The MCO may make a determination on any number of factors and only quality metrics may determine how quickly they respond. DC area licensed physicians may be involved in the decisions, but they are not required to be. Woman #1 may have resolution and her prescription while Woman #2 must wait for her medical treatment, all because of their insurance type. Considering one of the DC MCOs in 2019 denied almost 20% of claims from the District, this person has a good chance of not even receiving her medication.

Recently CMS released new prior authorization guidance for public plans that takes some of the same elements as the DC law and puts them into effect in two years. DHCF should get started now on complying with DC and federal law and adopt the requirements of B25-124. While we recognize that this is a challenging budget year, this type of health equity issue cannot wait and the gap in care will become apparent as the District’s prior auth law goes into effect.

Please reach out to the MSDC office if our membership can be of assistance on these or any issue. We look forward to working with you and the Committee to make DC the nation’s model for patient care and physician practice.

Klint Peebles, MD FAAD
Director, Medical Society of DC