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B
Good
morning,
labor
Health
and
Social
Services
committee
welcome
to
day
two
of
our
third
meeting
of
2023.
We
do
have
a
full
agenda
this
morning,
two
bills
up
before
us
generally
dealing
with
similar
topics.
Well,
I'll
call
White,
bagging
and
prior
authorization.
We
will
discuss
the
prior
authorization
bill.
First,
that's
24,
lso,
68,
working
draft
seven.
So
for
those
of
you
newer
to
the
legislative
process,
seven
different
revisions
of
this
bill
thus
far
and
some
Lively
comment
today.
B
Unless
anybody
has
any
opening
announcements,
we'll
just
kick
right
in
Miss
Johnson,
if
you
would
walk
us
through
lso
draft
68
on
prioroff.
C
C
C
26
55
107
provides
requirements
applicable
to
persons
receipt,
reviewing
adverse
determination,
appeals
and
then
2655
108.
On
page
15
requires
Health
insurers
to
advise
Health,
Care
Providers
of
an
authorization
or
adverse
determination
within
five
business
days
of
receiving
the
prior
authorization
request
of
the.
If
the.
If
the
request
is
non-urgent
on
page
16,
if
the
prior
authorization
request
is
urgent,
the
health
insurers
shall
notify
the
health
care
provider
of
the
authorization
or
adverse
determination
not
later
than
24
hours
after
receiving
all
necessary
information
to
complete
the
review.
C
If
prior
authorization
is
required
for
treatment
of
a
chronic
or
long-term
care
condition,
the
authorization
shall
remain
valid
for
one
year.
2655
112
regards
continuity
of
care
for
enrollees.
If
a
person
switches,
Health
insurers,
a
prior
authorization
for
a
medical
service
shall
remain
valid
with
the
new
insurer
for
90
days.
If
the
health
care
services
a
covered
benefit
under
the
new
health
insurance
plan.
During
that
time
period,
the
new
health
insurer
May
perform
its
own
review
to
Grant
a
new
authorization
26
55
113,
starting
on
page
21,
regards
provider,
exemptions
from
prior
authorization
requirements.
C
A
healthcare
provider
should
be
granted
granted
an
exemption
from
completing
a
prior
authorization
request.
Even
the
most
recent
12
12-month
period,
Health
insurer
has
authorized
not
less
than
80
percent
of
the
prior
authorization
requests
submitted
by
the
health
care
provider
and
the
health
care
provider
has
made
a
prior
authorization
request
for
that
procedure,
not
less
than
five
times
in
the
previous
12
months.
C
The
staff
comment
on
page
21
indicates
that
the
language
would
have
authorized
was
removed
from
the
draft,
because
the
phrase
is
vague
and
confusing,
and
the
staff
come
on.
Page
22
indicates
that
enrollees
just
cautioning
the
committee
that
enrollees
may
seek
out
doctors
that
they
know
are
receiving
exemptions
for
certain
procedures
so
that
they
do
not
have
to
go
through
the
prior
authorization
process.
C
C
The
health
insurance
May
revoke
an
exemption
if
it
makes
a
determination
that
the
health
care
provider
would
have
met
would
not
have
met.
The
80
approval
threshold
provides
the
health
care
provider
with
the
information
it
relied
on
to
make
the
determination
and
provides
the
health
care
provider
with
information
on
how
to
appeal
the
decision.
The
staff
comment
on
page
26
indicates
that
the
severability
section
of
the
bill
draft
was
removed
because
separability
is
already
covered
in
statute
and
then
2655
114
is
a
new
section
that
was
added
since
the
last
meeting.
C
It
indicates
that
a
health
insurer
shall
not
require
prior
authorization
for
rehabilitative
or
habilitative
services
for
the
first
12
visits
for
each
new
episode
of
care.
Section
2
indicates
that
the
department
of
insurance
has
rule
making
Authority
and
section
3
provides
for
a
split
effective
date
and
I
would
stand
for
any
questions.
B
Not
seeing
any
at
this
time
so
we'll
just
jump
right
in
maybe
a
little
bit
off
script
today,
because
I
know
a
lot
of
you
are
familiar
with
this
issue,
but
you're
all
with
organizations.
Is
there
any
just
member
of
the
public
who's
here
to
talk
about
prior
authorization?
Who
would
like
to
go
first
I
know
we
have
Miss
CEO
Mincey
from
the
Saratoga
hospital
here.
B
I'll
probably
call
him
up
to
go
first,
just
because
I
know
you
have
a
hospital
to
run,
but
if
there's
any
other
public
comment,
okay,
Mr,
if
you
would
come
on
down
Mr
minsey,
trying
to
be
certainly
respectful
of
your
time
unless
everybody
else
is
kind
of
being
paid
to
be
here.
And
but
if
you'd
like
to
kick
us
off
and
thank
you
for
hosting
us
yesterday
evening
at
your
beautiful
facility
and
Mr.
D
B
We
tried
we
can
welcome
Mr
mincy
floor
is
yours.
Talk
to
us
about
prior
Roth.
E
Yeah
good
morning,
chair
Baldwin,
chairser,
senators
and
representatives.
Thank
you
for
coming
to
our
facility
yesterday.
It's
always
a
pleasure
to
talk
about
what
we're
doing
prior
authorizations
is
a
is
a
part
of
a
bigger
challenge
for
health
care.
One
of
the
things
that
we
run
into
in
healthcare
is
is
overly
burdensome
regulation
and
overly
burdensome
Contracting
with
insurance
carriers.
E
Look
at
my
business
office
in
comparison,
I
have
14
full-time
people
working
in
the
business
office.
Their
job
is
to
deal
with
insurance
companies
and
regulations.
Prior
authorizations,
I
have
one
LPN
that
spends.
She
spends
anywhere
from
eight
to
ten
hours
a
week
just
on
on
prior
authorizations.
I
have
three
other
full-time
employees
in
the
in
the
business
office
that
also
spend
eight
to
ten
hours
every
week,
dealing
with
prior
authorizations.
The
vast
majority
of
the
time
that
they
spend
on
prior
authorizations
is
on
hold.
E
My
my
clinic
nurse
said
you
know
if
everybody
would
do
the
do
this
website
and
I'm
sorry
I,
don't
know
which
website
it
was,
but
they
said
if
everyone
would
do
this
website,
where
I
could
take
five
minutes
put
in
the
information
that
they
need
and
I
can
come
back
later
and
get
an
answer,
then
I
can
spend
more
time
taking
care
of
patients
it's
this
is
not
a.
This
is
not
a
challenging
decision
to
to
decide
are,
are
prior
authorizations,
overly
burdensome
they
indeed
are
and
I
support
this
bill
completely
it
will.
E
It
will
improve
the
amount
of
time
that
my
staff
have
to
actually
do
what
we
want
to
be
doing
and
that's
taking
care
of
people
the
burden
that
we
see
from
the
insurance
carriers.
Is
it's
the
vast
majority
of
our
administrative
folks
time
there?
They
want
to
tell
you
that
it's
it's
about
what
we
charge.
It's
about.
You
know
it's,
it's
all
about
we're.
The
problem.
E
I
would
challenge
you
to
look
at
and
see
who
the
problem
is
when
most
of
us
are
struggling
to
break,
even
we're
relying
on
local
donations
and
tax
dollars
to
keep
our
doors
open
and
every
one
of
them
are
posting
billions
of
dollars
in
profits
quarterly.
It's
it's
not
the
health
care
provider.
That
is
the
problem,
so
I
I
highly
encourage
you
to
support
this
Bill
and
I'm
happy
to
answer
any
other
questions
you
may
have
regarding
regarding
this
bill.
F
B
B
For
your
time
yesterday
and
this
morning,
all
right,
no
other
public
comment.
Let
me
just
check
online
I
think
there
are
three
industry
people
in
the
room
waiting
and
Miss
Herman
with
that
insurance
company,
hi,
Blue,
Cross,
Blue
Shield,
welcome
to
Saratoga.
B
Oh,
it's
a
pleasure
seeing
you
miss
Road
day
and
I.
Think
committee:
you
were
provided
a
handout
and
a
letter
in
an
email
two
days
ago
with
some
suggested
amendments
in
a
priority
order,
which
I
appreciate:
welcome,
Miss,
Roday
closures,.
G
We
are
gathered
here
today
to
discuss
some
complicated
pieces
of
legislation
and
we
are
all
collectively
tackling
complex
topics
where
we
are
trying
to
balance
the
needs
of
those
who
are
providing
care
with
those
who
are
paying
the
bills
for
that
care,
and
these
positions
are
naturally
at
odds
with
each
other,
while
providers
and
hospitals
are
facing
Rising
costs
and
inflation.
So
too
are
our
members
and
our
business
clients,
who
are
also
our
neighbors.
We
are
indeed
a
Wyoming
company
and
most
of
our
employees
live
and
work
in
Wyoming.
G
G
G
However,
we
continue
to
have
concerns
and
we
offer
the
attack
the
attached
amendments
that
are
before
you
to
address
them.
Our
priorities
are
not
in
the
order
presented
by
the
Amendments,
but
are
as
follows,
and
we
talked
a
little
bit
about
the
prioritization
so
number
one.
The
required
consultation
with
providers
before
a
claimed
denial
presents
some
concerns
for
us,
with
an
average
of
20
claim
denials
occurring
every
day.
This
language
will
require
our
Pharmacists
and
medical
directors
who
are
Physicians
to
spend,
in
some
cases
over
50
percent
of
their
days
contacting
providers
and
members.
G
G
We
appreciate
we
do
appreciate
the
willingness
of
others
to
give
us
72
hours.
The
definition
of
Health
Care
Services
needs
to
be
further
defined
into
inpatient,
outpatient
and
prescription
drug.
The
timing
of
Prior
authorization's
lengths
vary
according
to
the
type
of
service,
so
one
year
is
not
appropriate
for
all
prior
authorizations.
G
We
are
con
so
number
four.
We
are
concerned
that
the
practice
of
gold
carding
will
continue
to
be
Mis,
contribute
to
misuse
if
providers
do
not
abide
by
established,
Criterion
and
perform
Services,
which
otherwise
would
have
been
caught
by
Prof
prior
authorizations
and
Amy
actually
has
an
example
of
this.
H
Good
morning
in
2018,
Blue
Cross
Blue
Shield
of
Wyoming
ended
its
gold
carding
process.
We
had
a
gold
carding
process
for
many
years
for
on
the
outpatient
procedure
code
side.
During
that
time
we
felt
that
there
may
be
issues,
but
we
were
unable
to
find
those
in
the
data
because
we
weren't
receiving
the
prior
authorization
records.
H
Blue
Cross
Blue
Shield
of
Wyoming
has
a
smaller
staff
and
at
that
point
in
time
we
did
not
have
the
ability
to
do
aggressive,
post
payment
auditing,
meaning
when
the
claim
comes
in.
We
do
not
wish
to
order
records
and
slow
the
payment
down
to
the
provider
we
found
when
we
closed
the
gold
carding
process
that
we
had
clinics
who
were
rendering
services
not
in
accordance
with
medical
guidelines
and
that
we're
raising
premiums.
H
H
Our
concern
is
that
there
are
areas
of
medicine
like
this,
where
there
could
be
these
unintended
consequences
that
we
may
begin
to
see
and
those
may
impact
the
member
who
did
not
have
a
chance
to
be
part
of
the
conversation
prior
to
Services
being
rendered
meaning.
The
insurance
company
then
denies
a
portion
of
the
claim
that
then
becomes
the
member's
responsibility
after
services
are
rendered.
G
Thank
you,
Mr
chairman
So,
based
on
our
actual
experience.
We
suggest
that
this
section
be
deleted
for
prescription
drug
prior
authorizations.
It
is
important
to
include
FDA,
approved
dosage
and
duration
criteria
in
the
language,
because
it
is
the
Federal
Drug
Administration,
the
FDA,
who
determines
how
drugs
should
be
safely
and
appropriately
used
in
the
U.S
so
number
six.
Regarding
opioid
abuse
treatments.
We
acknowledge
that
there
is
an
opioid
abuse
epidemic.
However,
our
pharmacists
have
shared
concerns
with
us
about
that
without
any
prior
authorization,
the
prescriptions
used
for
treatment
can
also
be
abused.
G
Our
current
practices
apply
quantity
level
limits
on
the
treatment,
drugs
and
encourage
visits
with
providers
periodically
to
ensure
their
safe
treatment
without
the
ability
to
apply
evidence-based
quantity
level
limits
to
the
treatment
drugs
and
encourage
members
to
check
in
with
their
providers
periodically.
We
cannot
support
this
language
and
would
like
it
removed
when
State
legislation
impacts
benefit
design.
It
is
preempted
by
federal,
erisa
law
and
therefore
we
request
the
removal
of
reference
to
coverage
on
page
20
and
I.
Believe
Mr
Spencer
will
talk
more
about
that.
G
We
would
like
to
have
the
flexibility
regarding
urgent
definition
for
mental
and
Behavioral
Health
Care
Services,
and
would
like
to
change
the
shell
to
May,
and
that
is
amendment
number
two.
So
this
is
our
prioritized
list.
We
hope
the
committee
will
continue
consider
these
suggestions
to
improve
prior
authorization
process
from
the
current
state
and
we
stand
for
questions.
B
D
Thank
you
Mr
chairman.
Did
you
deny
prescriptions
for
Ivermectin
during
the
scandemic.
B
I
Thank
you,
Mr
chairman
good
morning,
members
of
the
committee
Mr
chairman
Bruce
Spencer,
representing
the
Mountain
Health
Co-op
I'll,
make
a
couple
of
just
overall
arching
statements
and
then
get
into
the
Amendments.
You
know
I
understand.
I
Prior
authorization
is
a
thorn
in
the
side
of
providers
and
that's
why
we
health
plans
have
worked
to
try
and
craft
a
bill
that
is
fair
and
Equitable
and
does
address
some
of
the
concerns
providers
have
about
prior
authorization,
but
insurance
companies
are
fiduciaries
of
the
funds
that
individual
people
in
Wyoming
give
us
to
pay
for
claims.
I
I
The
prior
authorization
is
not
designed
to
prevent
adequate
patient
care
or
proper
patient
care
is
designed
to
help
with
our
fiduciary
responsibility
to
that
member
now,
of
course,
there's
necessary
tensions
in
the
process
anytime.
Somebody
is
telling
somebody
else
that
we're
not
going
to
approve
something
you
have
necessary
tensions.
I
Mountain
Health
Co-Op
agrees
with
the
Amendments
presented
by
Blue
Cross
Blue
Shield
I
do
want
to
talk
about
one
in
particular,
That
Mountain,
Health
Co-Op,
presented
in
its
letter
and
amendments
to
you,
and
that
is
the
continuity
of
care
for
enrollees
25,
55
112.,
it's
on
page
20
of
the
bill.
What.
I
It's
on
page
four
by
handout,
and
it
would
be.
I
B
I
Page
four:
this
is
on
page
20
of
the
bill
for
the
bill
language,
the
sub
paragraph
C,
and
the
continuity
of
Caravan
release
and
I
apologize.
That
I
didn't
bring
this
up
sooner
in
the
process,
but
sometimes
when
you're
reading
through
things
they
just
pop
out
at
you
and
as
a
lawyer.
This
time
this
popped
out
at
you,
the
first
sentence
of
sub
paragraph
C
says:
if
there
is
a
change
in
coverage
of
or
a
change
in,
approval
criteria
for
a
previously
authorized,
Health
Care
Service.
Basically
that
person
is
grandfathered
in
for
one
year.
I
Well,
there
isn't
a
problem
with
change
in
approval
criteria.
Right
I
think
we
all
agree
that
if
you
got
prior
approval
and
the
insurance
company
then
changes
the
prior
approval
criteria,
you
shouldn't
have
to
go.
Do
that
again,
so
the
one
year's
fine
of
that
but
I
do
have
a
big
concern
with
the
use
of
the
term
coverage
of
and
I
I
think
this
is
just
an
unintended
consequence.
I'm
not
exactly
sure
what
was
intended
here,
but
change
in
coverage
of
means
that
if
an
insurance
company
decides
in
say,
let's
use
2024
as
an
example.
I
Okay,
what
this
bill
says
is
that
if
you
got
a
prior
auth
for
that
procedure
in
February
of
23,
now
you
are
in
a
special
class
of
person
that
isn't
subject
to
that
decision
to
remove
that
procedure
from
coverage,
and
so
now
you
have
two
different
classes
of
people.
You
have
regular
members
who
haven't
gotten
prior
authorization
that
are
not
covered
for
that
procedure
and
somebody
that
is
covered
because
they
got
a
prior
authorization
up
to
a
year
before
the
change
in
coverage.
I
I
For
anybody
that
received
a
prior
auth
up
to
a
year
before
that's
I,
think
a
step
too
far
and
I'm
not
really
sure
it
was
intended.
I
I'm,
not
sure
that
that
was
intended,
so
I
do
have
as
a
lawyer
a
big
concern
about
that.
I
think
it
could
cause
problems
legally
for
the
bill
in
the
future.
If
it's
there
and
it's
an
easy
fix,
you
just
have
to
take
out
the
word
coverage
of.
In
that
paragraph.
I
As
I
said,
we
agree
with
Blue
Cross
Blue
Shield
on
their
suggested
amendments.
I
did
provide
amendments
in
order
of
priority
for
my
own
Health
Co-Op.
That
order
would
be
to
address
the
24-hour
turnaround
on
urgent
I.
Think
it's
important
for
the
committee
to
understand
the
difference
between
urgent
and
emergency
I
know.
Ms
Roday
mentioned
that
these
are
not
emergency
situations.
I
I
Yeah,
so
we
also
have
concerns
about
the
consultation
required
before
a
plan
is
going
to
deny
in
prior
authorization
a
request,
and
the
bill
says
that
the
plan
has
to
reach
out
to
the
physician,
and
then
they
have
the
opportunity
for
an
in-person
consultation
that
creates
a
level
of
bureaucracy
that
is
not
in
any
other
prior
authorization
bill
that
Mountain
Health
Co-Op
has
to
address
and,
as
you
heard,
the
the
gentleman
from
the
hospital
say
they
spend
a
lot
of
time
on
their
phone
waiting
for
conversations.
I
I
I
I
sent
them
to
my
client
for
review
and
approval,
and
then
I
submitted
them
to
you
and
I
want
to
explain
why
that
allegation
that
I
submitted
a
patently
false
allegation
to
this
committee
is
so
important
and
vital
to
what
I
do
as
a
lobbyist,
all
I
have
and
a
lawyer.
Frankly,
all
I
have
is
my
reputation
with
you.
I
I
I
can't
operate
by
the
political
campaign
standard
of
well,
maybe
down
on
a
footnote
in
a
committee
or
a
hearing
or
an
ad
three
years
ago.
I'll
get
to
make
some
statement.
I
can't
operate
on
that
standard.
You
should
demand
for
me
and
every
other
person
that
appears
here.
Absolute
truth,
nothing
less
is
acceptable,
and
so
that
allegation
is
incredibly
damaging
to
what
I
do
and,
in
my
belief,
in
this
public
policy
process,
I
have
an
ethical
obligation
as
an
attorney
to
prep
to
give
Candor
to
courts.
I
cannot
tell
a
lie
in
court.
I
I
B
B
I
It
is
a
challenge
to
meet
that
Benchmark.
Our
TPA
University
of
Utah
health
plans
invests
significant
amounts
of
resources
to
meet
that
20.
A
48-hour
turnaround.
They
felt
the
72
hours
is
much
more
attainable.
Do
we
have
complaints
about
them,
not
meaning
that
I'm
not
aware
of
any
it's
just
that
it?
It
costs
money
and
staff
and
time
to
meet
that
turnaround,
and
with
that
Consulting
requirement
that
we
have
currently
in
the
bill,
it's
going
to
cost
Physicians
money,
staff
and
time
and
providers,
money,
stuff
and
time
to
meet
that
requirement.
F
I
Mr
chairman
Senator
dockstetter,
all
the
above,
so
certainly
the
discussion
that
we're
having
about
the
Urgent
turnaround
time
that
that
is
a
Paramount
importance.
My
folks,
at
the
University
of
Utah
health
plan,
told
me
24
hours
is
a
standard
that
is
very,
very
difficult
to
meet
and
they
don't
feel
they
could
they
could
do
it
at
this
point
in
time.
You
know
we're
not
they're,
not
we're,
not
a
big
big
multi-conglomerate
insurance
company.
That
has
the
ability
to
program
all
this.
I
So
it's
all
electronic
at
this
point
we're
all
working
towards
that,
but
we're
not
there.
Yet
that
requires
significant
resources,
so
that
would
be
number
one
to
agree
with
the
providers
in
their
letter
that
they
72-hour
turnaround
time
is
appropriate.
I
Do
you
have
your
list
of
amendments?
Maybe
I
can
just
take
a
look
at
one.
Two.
Three
sorry
I
gave
you
my
list,
but
I
didn't
look
at
it
there
last
time,
I
do
agree
with
their
list,
so
that
would
be
my
heart.
The
second
one
is
is
that
care
coverage
that
I
spent
some
time
discussing
about.
That
would
be
our
second
priority.
I
And
then,
finally,
I
have
to
go
to
my
amendments,
which
are
always
difficult
because
I
did
put
them
in
order
yeah
removing
on
page
12
of
the
bill
lines,
one
through
15.,
which
is
that
Consulting
prior
to
the
adverse
decision.
Those
would
be
our
top
three
one.
B
I
Chairman
members
of
the
committee,
that
is
now
a
slightly
complicated
question
from
Montana,
we
had
a
standard
gold,
carding
Bill
submitted
last
session.
It
was
probably
not
going
to
pass
and
the
mental
health
care
providers
wanted
some
gold
carding
standards
for
specific
drugs
that
they
use,
they're,
really
urgent
in
certain
mental
health
circumstances
suicidal
folks,
and
so
we
entered
into
a
compromise
where
those
providers,
if
they
meet
a
90
standard,
not
an
80
percent,
as
is
in
this
bill.
F
Spencer
we
respect
your
professionalism
and
your
integrity
and
if
a
member
of
the
body
left
that
in
question,
I
will
apologize,
but
you
also
have
the
Avenue
bringing
up
that
matter.
If
it
is
a
member
of
the
legislative
body
with
the
leadership
team
of
the
committee
and
the
leadership
of
the
legislature
as
well,
we
try
to
keep
this
respectful
and
keep
the
dignity
involved
times.
We
stumble
and
just
leave
that
option
open.
Do
you
appreciate
your
work,
appreciate
your
integrity
and
appreciate
the
tradition
of
your
family's
Shield?
Thank
you.
I
J
Yes,
thank
you
Mr
chairman
to
any
of
you,
I
guess.
One
of
the
problems
in
Wyoming
is
we're
the
only
state
without
prior
authorization
and
as
you're
trying
to
get
things
authorized.
It's
there's
a
huge
difference
between
every
company
that
you
work
with
when
I
look
at
the
24-hour
urgent
and
then
I
look
at
the
five-day
for
other
authorizations,
I
mean
now.
We
have
an
hour
thing
and
we
have
a
day
thing
and
also,
as
a
provider
you're
gonna
have
to
figure
out.
Is
this
urgent
or
not
urgent?
J
How
would
you
feel
if
it
was
72
hours
period?
Keep
it
consistent
across
all
plans
that
way
the
providers
know
exactly
what
to
expect
the
insurance
companies
know
what
to
expect.
I
So
Mr,
chair,
representative
I'll,
start
out
because
my
company
does
right
in
three
states
and
in
all
all
but
Wyoming,
and
we
absolutely
agree.
Wyoming
needs
some
additional
priority.
You
have
some
already
by
the
way.
It's
not
true
that
you
don't
have
any
prior
auth
regulation
in
the
state
of
some,
but
you
absolutely
need
additional
and
we're
not
disputing
there
are.
All
of
our
other
states
are
exactly
that:
hybrid,
okay,
it's
it's
a
it's
an
hours
for
Urgent
and
then
it's
five
business
days
for
non-urgent.
That's
the
standard
in
every
other
state.
I
We
have
no
problems
complying
with
that
and
everybody
understands
generally
the
difference
between
an
urgent
request
and
a
non-urgent
request
that
we
just
haven't
seen
those
kinds
of
administrative
problems
with
us:
I'll
I'll,
let
Ms
Roday
or
someone
answer
things.
Foreign.
K
K
The
one
thing
I
will
say
about
addressing
your
specific
question
is:
if
all
of
the
prior
authorizations
were
set
at
72
hours,
it
may
be
hard
to
sort
of
prioritize
those
urgent
requests
over
the
top
of
something
that's
more
of
a
general
and
regular
request,
so
it
might
just
get
caught
in
the
same
bucket,
and
we
do
in
fact
want
to
prioritize
anything
that
might
be
urgent,
anything
that
might
be
causing
pain
to
a
member
or
anything
that
might
be
sort
of
putting
them
in
a
space
where
they're
you
know,
their
life
might
in
some
way
be
put
put
a
challenge,
and
you
know
we
don't
expect
to
wait
a
full
72
hours
if
we
get
an
urgent
request
and
we
can
answer
it
within
an
hour.
K
Of
course,
we
want
to
do
that.
It's
just
a
matter
of
timing.
It's
just
a
matter
of
the
amount
and
the
volume
that
we
receive
so
I
could
see
that
being
a
challenge
and
I
think
it
does
make
some
sense
to
set
them
into
separate
buckets.
I
may
defer
to
Amy
over
here
for
for
some
additional
comments,
but
just
to
answer
a
couple.
K
Other
questions,
if
I
may
representative
ward,
in
the
spirit
of
being
you
know,
open
and
honest
with
the
committee,
we
we
have
denied
Ivermectin
requests
for
not
meeting
utilization
management
requirements.
K
So
I
did
want
to
let
you
know
that
our
pharmacist
just
texted
me
and
let
me
know
that
we
have
done
that
I,
don't
have
all
the
specific
details
for
you
and
I
can
provide
that
if
you,
if
you'd
like,
but
I,
can
confirm
that
we
have
denied
those
requests
and
then
I
wanted
to
make
one
other
comment,
which
is
a
representative
from
the
local
hospital
here
made
mention
of
a
website
and
I
think
what
they
were
referring
to
was
our
availity
website
that
Blue
Cross
Blue
Shield
of
Wyoming
uses,
and
that
has
been
a
very
good
tool
in
the
prior
authorization
process,
I
think
for
providers.
K
So
the
only
other
thing
I
would
say
is
you
know
the
comments
that
we
provided
today
were
in
no
way
meant
to
be
offensive
in
any
way
or
or
to
to
members
of
the
provider
Community
or
anything
like
that.
Like
I
said
Solutions
like
availity
and
other
Solutions
out,
there
are
a
little
bit
less
I
guess
prescriptive
than
some
of
the
rules
that
are
set
out
in
this
bill,
and
you
know
looking
at
this
bill
and
some
of
the
requirements
that
are
in
it.
K
It
looks-
and
this
is
just
my
personal
opinion
to
be
setting
a
precedent
to
start
putting
things
in
sort
of
the
AI
track
and
and
that's
not
necessarily
something
that
we
want
to
do
right.
I
mean
we.
We
would
prefer
to
allow
a
human
touch,
people
to
be
reviewing
things,
our
local
doctors
and
Physicians,
to
be
able
to
look
at
things
as
opposed
to
just
sending
them
into
a
computer
system
and
spitting
them
out
at
people.
So
that's
everything
for
me.
B
B
Can
I
ask
I,
guess
one
more
question,
then,
when
it
comes
to
this
kind
of
gold,
carding
concept,
do
you
are
there
internal
mechanisms
where
you
could
internally
say
this?
Mental
health
provider
sees
high
risk
patients
on
a
routine
basis?
We
haven't
had
any
concerns
and
there's
a
note
in
the
system
that
you
know
absent.
Other
information
they
get
approved
kind
of
automatically
I
mean.
Do
you
need
a
statute
to
tell
you
to
allow
gold
carding
if
you
as
a
company,
wanted
to
do
something
similar
call
it
whatever
you
want?
H
Thank
you
for
the
question
from
Blue
Cross
Blue
Shield
of
Wyoming.
There
are
mechanisms
that
could
allow
that
practice.
Since
2018,
we
have
solely
focused
on
removing
authorization
requirements
at
the
code
level,
so,
instead
of
focusing
on
one
provider
or
two
providers
in
a
space
say,
can
we
eliminate
prior
authorization
in
that
space
for
a
particular
procedure?
One
of
the
items
we
have
seen
as
a
company
that
is
difficult
to
navigate
is
sometimes
the
larger
practices
have
a
larger
voice.
H
They
have
the
amount
of
claims
that
we
can
really
go
through
analytically
and
say
this
is
a
provider
who
should
be
given
some
allowances,
but
what
that
does
is
it
does
not
allow
for
the
smaller
practices
to
see
that
impact,
and
typically
the
smaller
practices
are
who
have
difficulty
with
the
prior
authorization
process.
Different
insurers
have
different
requirements
and
rules.
So
when
you're
a
small
practice
trying
to
navigate
that
it's
very
difficult,
so
we
felt
we
should
look
at
the
larger
picture
than
at
a
provider
specific
picture.
B
L
You
Mr
chairman,
could
any
of
you,
and
maybe
each
of
you
give
me
an
estimation
of
what
you
think
you.
The
rates
of
urgent
requests
versus
non-urgent
requests
are
that
you
process.
H
Urgent
requests
are
typically
around
50
percent
from
their
submission
on
the
outpatient
side,
typically
from
initial
submission,
it's
around
60
percent
are
submitted
as
urgent
when
we
look
at
processing
them,
though
our
physician
staff,
not
our
nurses,
our
physician
staff
does
change
that
urgency
and
we
usually
process
around
10
percent
as
actually
urgent.
Our
largest
category
of
urgent
submissions
is
the
Dermatology
Community
or
the
orthopedic
Community,
which
is
typically
not
seen
as
Urgent
Care.
H
I
You
Mr
chair,
Senator,
representative,
Penn,
I,
don't
know
the
specifics,
but
I
can't
imagine
that
our
population
is
all
that
different
from
Blue,
Cross
and
Wyoming,
so
I.
Imagine
it's
a
similar
percentage.
I
do
not
know
whether
or
not
the
physicians
at
University
of
Utah
changed
that
designation.
I
can
find
out.
If
it's
very
important
to
you
and
get
back
to
you.
M
Thank
you,
Mr
chairman
I'm,
just
looking
through
how
many
states
have
the
24-hour
urgent
care
prior
authorization.
G
B
M
Yeah
follow-up,
Mr
chairman.
M
M
M
Why
wouldn't
this
be
possible
in
Wyoming
with
a
small
state
with
you
know,
we
don't
have
two
million
people
to
that
are
going.
You
know
so
many
hospital
visits
in
other
states.
Why
wouldn't
this
be
possible
in
Wyoming.
H
So
a
couple
of
items
that
are
difficult
in
the
24-hour
time
frame:
one
is
a
truly
resource
allotment,
so
at
Blue
Cross,
Blue
Shield
of
Wyoming.
We
employ
two
medical
directors
or
MDS
that
are
making
decisions
and
we
have
a
nursing
staff
of
nine.
Typically,
our
two
medical
directors
who
are
making
those
denials
are
also
practicing
Physicians,
so
the
resource
capacity
to
run
24
hours
a
day
seven
days
a
week
would
be
difficult
for
us
initially.
Obviously,
you
can
always
hire
additional
individuals
and
resource,
but
that
does
come
at
a
cost.
H
Secondarily,
24
hours
is
difficult
with
the
consultation
piece
of
the
bill,
so
I
do
worry
about
when
we're
reaching
out
to
Providers.
If
it
was
a
24-hour
time
period
on
a
denial
to
say,
can
we
have
that
conversation?
Many
of
our
practices
in
Wyoming
are
not
open
seven
days
a
week.
Many
of
those
that
would
be
receiving
denials
would
not
be
available
for
those
consultations
seven
days
a
week.
H
Another
issue
that
presents
itself
is
some
of
our
larger
institutions
in
the
state,
especially
hospitals
use
outsourced
billing
companies
for
authorizations
so
again
they're
working
24
hours
a
day.
Seven
days
a
week,
but
our
provider
community
and
our
payers
are
not
always
working
those
same
schedules,
so
an
authorization
that
comes
in
on
a
Saturday
may
not
have
a
treating
physician
available
to
Blue
Cross
to
speak
to.
Nor
do
we
typically
have
staff
working
those
hours,
so
it
makes
it
difficult.
L
Thank
you,
Mr
chairman
I,
guess
I
mostly
just
want
to
clarify
on
the
bill.
So
the
consultation
piece
is
on
page
12,
25,
50
or
26
55
106
and
it
doesn't.
It
doesn't
require
that
the
consultation
take
place.
It
just
says
that
the
opportunity
that
there
must
be
a
notification
that
there
may
be
a
denial
and
then
the
opportunity
is
there
for
a
consultation.
So
it's
not
requiring
that.
I
I
B
So
I
can
ask
a
question:
what
who
decides
urgent
urgency
is
it?
It
sounds
like
people
putting
claims
that
say
these
are
Urgent
and
you
say
these
aren't
urgent.
Is
it
a
code
that
these
are
Urgent
codes
or
does
the
submitting
practice
physician,
Etc,
say:
well
this
one's
urgent
and
you?
How
does
that
work.
H
So
typically
it
is
there's
not
a
code
for
it.
It
is
words
written
on
a
piece
of
paper,
so
typically
we'll
see
urgent,
expedited
written
on
it,
and
then
we
take
the
medical
records
and
present
those
to
a
physician
and
ask
them
to
review
those
against
the
Department
of
Labor's
urgency
standards,
which
is
also
very
similar
to
chapter
63
in
the
Wyoming
state
code.
B
H
Do
and
we
have
at
Blue
Cross
Blue
Shield
of
Wyoming.
We
don't
have
any
provisions
to
stop
the
practice,
so
there's
nothing
in
our
contracts.
So
we
do
have
those
conversations,
but
it
doesn't
seem
to
change
the
submissions.
However,
with
our
website
that
is
available
to
our
providers
now
in
real
time,
they
can
see
that
change
in
determination
and
there's
also
an
ability
to
see
the
comments
from
our
physicians
to
see
why
their
urgency
has
been
changed
so
that
there
is
real-time
communication
between
the
provider
and
Blue
Cross
Blue
Shield
of
Wyoming.
B
It
just
something
doesn't
make
sense
to
me
that
if
I
were
a
provider
and
I
wanted
it,
I
would
tell
the
patient.
We
put
an
urgent
request,
we'll
know
in
24
hours
and
then
it's
the
evil
insurance
company
you
know
is
still
holding
back,
even
though
it's
maybe
not
your
fault
is
that
is
there
another
way
to
fix
this?
Besides
the
word
urgent
and
who
gets
if
it's
by
code
I
can
see,
but
otherwise
everybody
says
something
is
urgent,
which
means
nothing
is
urgent.
H
Yes-
and
we
would
agree
with
that-
that's
the
principle
that
we're
trying
to
work
through
our
hope
is
that,
with
our
online
tools
that
are
available
and
continuing
to
enhance
those
that
we
being
more
transparent
and
providing
that
on
each
individual
authorization
can
possibly
serve
as
an
education
mechanism
to
provider
staff
in
helping
them
see
that
changing
this
does
not
actually
change
the
timeline,
but,
depending
on
the
language
of
the
bill,
we
may
not
have
that
ability.
B
D
B
H
I
Mr,
chairman
representative,
in
stakeholder
conversations
on
urgent
I
believe
the
provider
Community
is
very
concerned
about
putting
business
day
in
the
72-hour
or
24-hour
requirement.
It
is
in
the
non-urgent
it's
five
business
days
after
we
receive
all
necessary
materials,
so
I
know
they
have
great
concerns
over
that
and
I
will
represent
that
I
know
we
can
comply
with
72
hours,
not
business
days
on
the
Urgent
and
I
believe
the
providers
in
their
letter
to
you
indicated
that
that
was
acceptable,
and
so
we
would
urge
the
committee
to
sort
of
say
well.
I
B
N
Thank
you,
Mr
chairman
members
of
the
committee.
My
name
is
Kevin
Bond
I'm,
blessed
I'm,
the
executive
director
of
The
Board
of
Medicine
and
the
board
doesn't
usually
have
a
dog
in
the
fight
if
you
will
with
Insurance
bills,
and
so
that's
why
I'm
late
to
this
party
and
I
apologize
first
for
that
and
second,
as
lso
staff
pointed
out
to
me,
I
need
to
get
better
about
labeling
when
I
send
you
something.
N
I've
got
something
here
with
some
yellow
highlight
on
it,
and
if
it
was
my
wife's
classroom,
she'd
say
if
your
name's
not
in
on
it,
you
don't
get
a
grade.
So
hopefully
that
won't
apply
here.
But
I
I
only
bring
this
to
your
attention,
because
currently
in
the
Wyoming
Medical
Practice
Act
included
in
the
definition
of
practicing
medicine
is
the
rendering
of
a
determination
of
medical
necessity
or
appropriateness
of
proposed
treatment
and
I.
N
Don't
know
the
history
behind
that,
but
it's
in
place
been
in
place
for
an
extended
time,
at
least
in
all
my
time
at
the
board
of
17
years.
So
my
only
concern
then,
to
just
bring
to
your
attention
and
it's
not
a
for
or
against
it
simply
to
bring
it
to
your
awareness.
N
Is
that
if
you
go
to
the
second
page
or
actually
in
in
the
bill
on
page
11
and
then
on
page
13,
there's
basically
provision
that
allows
for
a
person
licensed
in
any
U.S
jurisdiction
to
make
a
determination
of
a
prior
authorization
on
prior
authorization
request.
And
that
would
seem
to
conflict
with
what
the
legislative
intent
was
in
the
past
to
say
that
a
determination
of
medical
necessity
is
actually
the
practice
of
medicine
or
a
health
care
profession.
N
So
what
I
have
suggested
as
an
option
for
you
all
on
the
second
page
of
my
unlabeled
handout
would
be
to
go
through
on
pages
11
13
and
basically
delete
the
language
that
says
that
that
a
person
rendering
a
finding
on
the
prior
authorization
I
would
not
be
licensed
in
any
state
territory
or
Commonwealth
of
the
United
States
or
the
District
of
Columbia
I'd,
rather
would
say
in
the
state
of
Wyoming,
which
would
be
more
in
keeping
I.
Think
with
that
intent
in
the
Medical
Practice
Act.
N
You've
got
much
bigger
fish
to
fry,
but
I
wanted
to
bring
that
to
your
attention
so
that
you
would
know
kind
of
what
the
the
balance
is
here.
The
board
doesn't
get
off
and
get
complaints
like
that,
but
we
we
do
on
occasion
and
I
suspect
the
Board
of
Nursing
mate
too,
when
they
have
nurses
making
determinations,
and
so
with
that
Mr
chairman
I'll
stand
for
questions
or
get
out
of
the
way
for
others.
So
questions.
M
You
Mr
chairman,
so
we
I've
heard
from
the
insurance
companies
that
it's
hard
enough
with
their
limited
staff
in
Wyoming,
to
make
some
of
these
make
some
of
these
determinations
and
were
within
the
bill.
Currently,
we've
got
a
24-hour
time
period,
which
complicates
it
even
further.
M
It
would
seem
to
me
like
if
we
opened
up
I
I,
understand
licensure
specific
to
Wyoming
and
how
important
that
is,
but
but
when
you're
dealing
with
just
prior
authorization,
it
would
seem
like
it
would
open
up
the
ability
to
have
the
24-hour
turnaround
much
easier
if
we
extended
the
parameters
to
be
licensed
in
the
United
States
of
America,
essentially
because
we
have
heard
in
the
past
also
how
you
know:
we've
all
done
it
where
you
get
on
the
phone
you
get
to
the
you
push
two
for
this
push.
M
Four
for
that
push!
Seven
for
this!
Listen,
listen,
push
the
zero
to
finally
talk
to
somebody,
and
you
can
hardly
understand
them
because
of
the
accent
and
and
who
knows
where
they
are.
So
you
know
there's
some
limitations
to
all
this.
M
Do
you
see
a
major
problem
with
what
we're
trying
to
do
here
to
just
open
up
the
the
doors
a
little
bit
to
somebody
licensed
in
America
versus
having
somebody
housed
in
Wyoming?
Being
a
licensed
physician
to
make
those
determinations
here
in
Wyoming
is?
Is
there
do
you
see
a
a
real
negative
consequence
to
to
opening
that
door
thanks.
N
Go
ahead,
Mr,
chairman
representative
hornock,
your
your
points
are
well
taken
and,
and
I
don't
disagree
with
them
and
I
think
that
on
the
other
hand,
for
instance,
the
carriers
that
do
carry
the
bulk
of
Wyoming
patients
in
their
on
their
book
of
business,
my
knowledge,
their
their
Physicians,
are
licensed
in
Wyoming.
But
I.
N
Guess
it's
just
a
question
of
accountability
for
that
professional
in
making
the
render
your
rendering
a
design
decision,
because,
like
it
or
not,
you're
going
to
get
then
sort
of
whatever
they
managed
to
hire
and
have
an
office
in
Nashville
or
whatever.
Just
a
personal
example.
N
I
I've
got
profound
hearing,
loss
on
one
side
and
I
had
two
different
ents
say
that
I
could
benefit
from
a
procedure
where
I
would
have
an
implant
put
in
kind
of
like
what
Rush
Limbaugh
had,
apparently,
but
not
quite
and
was
told
by
the
carrier,
who
happens
to
be
the
state
employees
plan
that
know
that
that
was
not
medically
necessary
was
not
covered.
N
You
know
my
hearing's
pretty
bad,
but
I'm
not
sure
it's
ranks
getting
a
urologist
to
make
a
decision
on
this,
and
yet
that
urologist
is
practicing
out
outside
the
scope
of
his
training
and
skill,
which
would
be
a
problem,
but
the
Hawaiian
Board
of
Medicine
probably
could
not
touch
them
because
they
weren't
licensed
in
Wyoming.
So
all
I'm
saying
is
that's
just
something
you
know:
there's
you
can't
move
one
piece
without
causing
something
else
to
move,
but
your
points
are
well
taken.
It's
it's
not
a
simple
solution.
I
think.
N
J
Thank
you,
Mr
chairman.
Thank
you
for
your
testimony.
You
know
it's
I,
don't
think
it
would
be
difficult
for
an
insurance
company
to
hire
a
physician
who
lives
in
Tennessee,
but
actually
has
a
Wyoming
license.
I
I,
don't
think
it'd
be
difficult
for
them
to
apply
and
get
a
license
in
Wyoming.
Do
you
think
that
would
be
an
arduous
task
for
them,
or
how
do
you
see
that
working
out
if.
N
Chairman
representative
Klausen
I
can
only
speak
to
what
our
experiences
we
have
about.
6
500
doctors
licensed
in
Wyoming
only
about
1400,
live
in
the
state
and
they're
licensed
for
all
sorts
of
different
practices
and
purposes,
not
the
least
of
which
is
doing
review
of
program,
authorization
requests
and
so
on.
We're
also
part
of
the
interstate
medical
licensure
compact.
A
lot
of
the
larger
National
practices
have
been
putting
their
Physicians
through
that
and
if
it
came
up
that
they
need
to
have
a
Wyoming
license
and
they're
already
in
the
pipeline.
N
For
that,
it's
as
simple
as
saying
here's,
my
credit
card
I
want
a
Wyoming
license
and
we
issue
it
within
a
very
short
period
of
time,
usually
24
to
48
hours.
So
it's
not
an
impossibility.
But
again,
if
you,
what
you've
chose
to
split
it,
I
would
say
if
you
can
just
see
your
way
clear,
to
include
the
termination
of
of
prior
authorization
determination
with
that
language
in
the
Medical,
Practice,
Act
I.
N
B
Me
Miss
Settles,
just
for
the
nursing
while
we're
on
boards
anything
on
this
bill
and
then
maybe
we'll
just
start
nuts
out
of
the
room
and
go
across
welcome
good.
P
Good
morning,
Mr,
chairman
and
members
of
the
committee,
my
name
is
Angus
mcalpin
I'm,
an
internal
medicine,
physician
in
Lander,
Wyoming
I'm,
a
primary
care
provider
at
Lander,
Medical,
Clinic
and
I'm.
Here
today,
as
a
community
provider
and
member
of
the
Wyoming
Medical
Society
board.
P
First
I'd
like
to
thank
you
for
your
time
and
attention
to
an
important
issue
in
medicine
right
now.
I
think
the
bill
as
written
is
an
important
step
in
improving
the
prior
authorization
process
and
in
removing
barriers
to
care
in
Wyoming.
P
I
can
largely
speak
to
Primary
Care
as
a
that's.
That's
where
I
practice,
but
I
think
my
comments
will
be
will
apply
to
Medicine.
In
general,
we
provide
as
Primary
Care
Providers
comprehensive
care
to
complicated
patients.
We
manage
Specialty
Care
arrangements
and
we
are
champions
of
preventive
services
at
lower
costs
and
improve
outcomes.
P
P
Peer-Reviewed
journals,
real-time
online
resources
to
make
my
medical
decisions
to
provide
evidence-based
care.
The
prior
authorization
process
is
not
part
of
this.
P
P
P
Regarding
the
gold
carding,
the
notion
that
providers
that
are
given
exception
for
requirements
that
they
would
fail
to
adhere
to
standards
of
care
is
is
offensive
and
medical
decisions
are
never
Guided
by
prior
authorization.
B
For
Dr
mcgaughton,
let's
start
with
senator
docson.
P
The
whether
something,
whether
there's
a
prior
authorization
requirement
or
not,
is
not
part
of
my
decision
I
would
assess
the
patient
figure
out
what
it
is
that
they
need
and
based
on
Expert
guidelines.
Evidence-Based
medicine
make
a
plan
of
care.
The
prior
authorization
comes
later,
if,
if
I
prescribe
a
particular
medication,
if
that
prior
authorization
process
is
is
required,
that
does
not
guide
my
initial
treatment
plan.
M
Thank
you,
Mr
chairman
I,
just
want
to
go
back
to
something
you
said
just
so
I'm
clear.
Obviously
we
have
a
you
know:
limited
staff
in
Wyoming
to
draw
from
for
medical
services,
but
you
said
that
sometimes
you've
seen
prior
authorizations
being
the
reason
that
people
leave
the
industry
is
is
have
you
do
you
have
personal
experience
with
that
or
or
is
I
just
want
to
make
sure
I
heard
of
that
right,
Dr.
P
The
prior
authorization
process,
I
I,
is
part
of
this
enlarging
administrative
burden,
that's
placed
on
practices
and
it's
that
administrative
burden.
That
I
think
is
driving
some
provider
burnout
and
causing
people
to
leave.
Primary
Care.
L
You
Mr
chairman
I,
just
want
to
say
hi
Dr
mcalpin,
we
are
called
co-workers.
We
work
in
the
same
Clinic,
so
to
speak,
to
what
representative
hornock
just
said
and
I
think
how
I
see
it
and
I'll
ask
your
opinion
as
well.
Dr
mcalpin
is
I.
Think
part
of
the
burnout
is
that
doctors,
oftentimes
are
not
being
allowed
to
practice
medicine.
L
It
seems
like
oftentimes,
the
insurance
companies
end
up
being
the
one
to
practice
the
medicine
we
just
try
to
decide
what
we
think
are
best
for
our
patients
and
then
later
on.
We
get
told
that
that's
not
the
not
best,
even
though
we
are
the
ones
that
are
sitting
in
front
of
those
patients,
you
know
toe-to-toe
and
trying
to
make
the
right
decisions.
I
might
liken
it
to
teachers
who
are
leaving
the
profession
because
they're
not
allowed
to
teach.
L
J
Thank
you,
Mr
chairman
doctors,
thanks
for
being
here,
you
know,
I
guess:
I
have
a
concern.
If
you
as
a
physician
order,
a
service
or
a
medication,
say
a
patient
needs
that
medication
they
go
to
the
pharmacy
that
day
and
then
they
have
to
wait
now
for
prior
authorization.
I
mean.
Do
you
see
that
happening
if
my
son's
hurt
and
he
needs
some
pain,
medication
and
I
go
to
the
pharmacy
I
want
to
get
that
medication
and
then
now
does
the
pharmacy
have
to
call
you
do
they
have
to
call
the
insurance
company?
P
Excuse,
yes,
I
believe
there
is
a
delay
in
care.
I
can
think
of
countless
examples
of
situations
where
I've
prescribed
a
medication
that
requires
authorization
and
there
is
a
significant
delay
and
that
can
result
in
harm.
In
my
opinion,.
Q
B
R
Morning,
Mr
chairman
members
of
the
committee
Sheila
bush,
with
the
Wyoming
Medical
Society
I,
have
brief
comments
prepared,
but
I
wanted
to
address
a
comment
made
earlier
regarding
an
accusation
and
I
just
I
think
it's
important
just
to
be
really
clear
about
what
that
was,
and
so
the
medical
society
emailed
all
of
you
privately
yesterday,
an
email
with
an
attachment.
R
It's
a
four-page
letter
written
by
our
physician
leadership
signed
by
our
president
and
so
the
the
language
that
was
addressed
earlier
I'm
going
to
read
to
you
just
because
I
think
it's
important.
If,
if
we're
going
to
talk
about
it,
let's
talk
about
it,
so
it
says:
Mountain,
Health,
Co-Op
MHC
suggests
that
if
a
patient
stopped
taking
a
drug
due
to
lack
of
efficacy,
the
prior
authorization
process
informs
providers
and
permits
a
different
therapy
to
be
ordered.
This
statement
is
patently
false.
R
Never
have
I,
president
chamber
been
informed
by
the
insurance
industry's
prior
authorization
process
that
a
patient
is
not
taking
a
medication
and
that
another
one
may
be
prescribed.
In
fact,
I
know
this
information,
because
I
continue
to
follow
each
patient
if
the
patient
is
not
adherent.
This
also
will
bear
out,
within
my
follow-up
evaluations
again
regardless
of
length
of
the
prior
authorization
approval.
R
Furthermore,
the
patient
is
not
going
to
pay
and
pick
up
a
medication
that
they
are
not
taking.
We
know
this
because
we
speak
with
our
local
pharmacies
and
it
is
partially
the
reason
that
we
can
identify
non-adherence
to
treatment
plans,
so
this
was
written
in
section
or
in
response
to
section
26
55
111,
which
has
to
do
with
the
length
of
a
prior
authorization
being
one
year
so
I
think
what's
possible.
Is
that,
like
so
many
things
there
is
what
is
in
policy?
R
It
may
or
may
not
be
that
it's
the
insurance
policy
to
talk
back
with
the
provider
and
say
this
medication
isn't
available
and
instead,
we've
we'd
suggest
these
I
think.
What
is
also
true
is
that
when
our
physician
leadership
I
have
a
26-member
board,
multiple
Physicians
reviewed
this
letter.
They
all
agreed
that
it
was
true
this
morning
when
the
issue
was
raised,
I
texted,
all
of
them
in
a
panic,
as
you
might
imagine,
nobody
wants
to
be
accused
of
misleading
or
any
of
that
and
that
wasn't
our
intent.
R
If
a
medication
has
been
denied,
but
instead
learns
in
a
follow-up
visit
with
the
patient,
that's
important,
and
so
it
isn't
in
any
way
intended
to
call
someone
a
liar
or
any
of
that
that
Integrity
wasn't
intended
to
be
called
into
question.
What
is
important
is
these
Physicians
do
believe
it
is
patently
false
that
that's
happening
in
their
practice
and
so
I'll
just
sort
of
leave
that
there
again
it
wasn't
ill
intended.
R
It
wasn't
meant
to
accuse
someone
of
of
intentionally
misleading,
but
I
think
it
does
draw
an
important
light
to
the
difference
between
what
insurance
companies
May
believe
is
happening
or
would
happen
on
a
perfect
day
in
policy
and
what
that
actually
looks
like
in
a
day-to-day
practice.
In
a
clinic,
which
is
what's
really
important
for
the
decisions
around
this
bill,
so
with
that,
unless
there's
questions,
yep.
F
Thank
you,
Ms
Bush,
for
your
professional
follow-up,
and
clarification
appreciate
that
I
want
to
understand
from
your
comments
the
first
that
a
physician
learns
that
his
prescription,
his
regimen
of
care
is
denied,
is
when
the
patient
comes
back
and
says
I
was
denied.
There
is
no
efforts
on
behalf
of
the
insurance
companies
to
work
with
that
physician.
R
Chairman
senator
dockstetter
I
lack
the
expertise
to
answer
that
in
detail.
We
have
a
prescriber
on
the
committee
and
Dr
mcalpin
is
still
in
the
room
and
I
think
if
we
want
to
get
into
the
real
Logistics
of
how
that
happens,
we
shouldn't
absolutely
do
that.
We
have
two
prescribers
in
the
room,
I'm,
so
sorry,
Senator,
Baldwin,
I'm,
all
it'll
be
years
that
and
I'll
pay
for
this.
Also
so
I
think
I.
Think
if
we
want
to
get
into
the
details
of
a
physician,
assesses
diagnosis
sets
a
treatment
plan
prescribes
a
medication.
R
Patient
leaves
goes
to
the
pharmacy.
What
happens
between
the
patient
and
the
pharmacy
I
think
is
important.
Miss
Carol
is
here.
She
can
also
speak
to
that.
There's.
A
lot
of
layers
to
this
I
think
that
the
the
initial
comments
submitted
indicated
that
insurance
believes
that
they
at
that
point.
If
they
aren't
going
to
authorize
that
medication,
they
call
or
directly
contact
the
provider
and
say
we're
not
authorizing
this
medication.
R
Do
you
want
to
have
a
substitute
therapy
or
a
different
medication
and
I
think
that
what
our
letter
said
is:
that's
not
what's
happening
there.
The
Physicians
aren't
being
consulted,
but
I'm
already
pretty
far
out
of
my
depth,
because
I
don't
prescribe
and
I
don't
see.
Patients
so
I
would
very
much
defer
to
the
prescribers
and
the
pharmacist
in
the
room.
B
S
Go
ahead,
thank
you,
Mr
chairman,
just
just
briefly
on
that
and
I'll
just
tell
you,
it
happens
in
a
number
of
different
ways,
depending
on
the
insurance
company
Etc,
but
typically
when
I'll
just
use
medicine
as
an
example,
I
prescribe
something
the
patient
gets
in
denial
and
I
get
a
denial,
a
similar
letter
and
I,
don't
know
if
representative
pen
similar,
but
a
similar
letter,
if
not
the
identical
same
letter
that
says
this
drug,
that
you
prescribed
is
not
authorized.
Sometimes
it'll
say
here's
your
options.
S
If
you'll
use
these
first
and
you
fail
on
these,
so
that's
one
of
the
ways
that
I
get
it,
but
generally
the
patient
gets,
gets
the
denial
and
the
prescriber
gets
in
denial.
We
both
get
it
and
that
may
come
through
the
pharmacist
as
well.
There's
another
way,
almost
daily
I
get
a
denial
from
a
pharmacist
on
a
medication
who
then
in
to
their
to
their
or,
to
my
delight,
they
help
me
a
lot
trying
to
find
the
right
drug
or
the
fight
right
medication
or
find
a
way
around
that
denial.
S
One
of
my
analysts
throw
this
out
there
since
I'm
talking
I
wasn't
going
to
talk
at
all
today,
but
one
of
the
denials
I
get.
That's
particularly
disturbing
to
me
is
when
I
have
a
patient
on
a
medication
for
a
long
period
of
time,
all
this
throughout
two
years,
and
that
patient
is
doing
very
well
on
that
medication,
be
it
antihypertensive
and
antidepressant,
whatever
the
case
may
be,
they're
doing
very
well
and
very
stable
and
I
get
a
denial
from
the
insurance
company
or
from
the
the
PBM
or
whoever.
That
is.
S
S
I
now
get
a
denial
for
that
medication
and
will
sometimes-
and
we
I
try
my
hardest
to
find
a
way
around
it.
But
we
end
up
going
back
to
another
drug
that
they've
yeah
and
it
it's
a
nightmare
and
I
think
of
my
nursing
home
patients,
my
long-term
care
patients
who
are
very
stable,
doing
very
well
and
we
throw
their
life
into
other
people.
When
that
happens,
that's
very
distressing
to
me
and
I
I
think
I
shared
with
the
co-chairman
this
morning
almost
daily,
and
it
seems
like
right
before
I
come
to
these
meetings.
S
Every
time
I
get
a
handful
of
denials
and
prior
authorizations
that
give
me
nightmares
at
night,
but
I
have
a
lot
to
think
about
when
I'm
here,
but
that's
typically,
the
way
it
happens.
Just
to
answer
that
question
is
the
patient
gets
a
denial,
I
get
denial
and
then
we
try
to
work
work
our
way
through
it.
B
Okay-
and
you
know,
everybody
up
here-
will
represent
a
lot
of
passionate
people
who
have
different
viewpoints
and
so
I
appreciate
that
you
represent
a
lot
of
people
with
passionate
viewpoints
and
we
all
know
how
this
works.
So
thank
you
for
that
explanation
and
it's
a
tense
bill
so
indeed
carry
on.
R
Thank
you,
so
my
comments
that
I
prepared
prior
to
that
sort
of
that
diversion
or
just
to
thank
you
I,
really
want
to
offer
my
appreciation.
This
is
really
important
to
people.
I
think
we
can
talk
for
a
while,
and
we
won't
today
about
the
access
shortage
in
our
state.
We
have
a
physician
shortage,
it's
hard
for
people
to
find
care
anything
that
this
committee
does
to
try
to
address
administrative
burden
and
allow
providers
to
deliver
the
care
to
the
patients
is
appreciated
and
deeply
needed.
R
I
think
it's
important
to
know
that
when
we
talk
about
cost
for
every
hundred
dollars,
that
the
US
government
spends
or
not
government,
but
like
the
United,
States
collectively
spends
on
Health
Care,
eight
dollars
and
fifty
cents
of
that
goes
to
the
Physicians
and
PAs
providers
actually
delivering
the
care.
R
The
rest
of
it
is
in
the
rest
of
this
system,
and
so
we
talk
about
prior
authorization
as
a
financial
tool
to
help
reduce
cost,
but
it
falls
on
the
shoulders
of
the
providers
who
are
delivering
the
care
and
have
the
expertise,
training
and
education
to
do
that
care
the
best,
but
the
prior
authorization
burden
falls
on
them,
in
addition
to
all
of
the
other
duties
and
responsibilities
that
we're
asking
of
them.
R
I
wanted
to
address
a
couple
of
specific
sections
in
terms
of
timeline
and
turn
around.
We've
discussed
this
I
think
throughout
the
interim
a
couple
of
times
our
initial
or
our
interest
in
compromising
has
been
mentioned,
and
that
is
true.
We
had
conversations
in
July
after
the
Evanston
hearing
with
the
medical
directors
of
Blue
Cross,
Blue
Shield,
and
it
was.
It
was
compromised
at
that
point
that
we
could
move
from
the
24
hours
to
72
hours
from
urgent.
R
But,
as
you
all
know,
compromise
takes
a
little
from
everyone,
and
so
part
of
that
compromise
was
not
just
the
72
hours
for
for
non-urgent.
It
was
also
then
120
hours
for
non-urgent,
so
72
hours
for
Urgent
120
hours.
For
non-urgent
not
right
now
it
reads:
24
hours
for
Urgent
and
five
business
days
for
non-urgent.
R
We
would
like
consistency
in
the
language.
We
do
think
that,
if
we're
going
to
use
hours
in
one
section
that
it
should
be
hours
throughout-
and
that
was
the
Compromise,
so
we're
willing
to
move
from
24,
there
is
precedent
for
24..
There
are
states
who
are
adhering
and
complying
with
24
and
doing
fine
with
that.
R
We
do,
in
the
spirit
of
compromise,
understand
that
our
our
payers
here
are
very
uncomfortable
and
feel
that
that's
not
something
that
they
can.
They
can
work
with,
and
so
in
trying
to
be
good
partners,
we're
happy
to
move
to
72
hours
from
urgent
or
to
for
urgent,
but
I
think
with
that
comes
120
hours
for
non-urgent
and
they
they're
packaged
they're.
Together,
that's
how
compromises
work,
that's
what
represents
a
little
bit
of
give
from
both
of
these
parties.
R
The
consultation
prior
to
denial
is
really
really
important
and
I.
Think
the
the
statement
made
earlier
by
representative
Penn,
the
language
is
really
clear
and
does
say
shall
be
given
the
opportunity.
It
doesn't
say
you
will
stock
and
track
down
that
doctor
and
ensure
that
you
have
the
conversation
prior
to
denial.
R
This
is
their
health
care,
sometimes
they're
in
a
deep
state
of
fear
and
they're
living
in
a
in
a
place
of
unknown,
and
so,
if
a
physician
has
decided
that
something's
really
important
this
longer
delay
or
yeah
delay
associated
with
prior
authorization
can
be
really
really
scary,
and
so,
if
a
physician
has
made
that
determination
in
their
medical
expertise
and
judgment
and
it's
going
to
be
denied
they
they
do
deserve
the
opportunity
to
at
least
say
we
can
talk
with
someone
and
and
give
more
context,
give
the
background
to
the
patient
give
their
unique
medical
history
whatever
the
situation
might
be,
but
it
doesn't
say
you
have
to
have
the
conversation.
R
It
says
the
opportunity
to
have
the
conversation
must
be
offered
and
we
don't
think
that's
unreasonable,
and
we
would
very
much
appreciate
that
remaining
in
the
bill
and
I.
Think
with
that.
I
would
just
close
by
saying.
You've
heard
some
examples
and
it
doesn't
matter
the
piece
of
legislation.
You'll
hear
examples
of
outliers,
and
so
I
I
will
never
stand
before
you
and
say
that
of
all
of
the
Physicians
licensed
in
Wyoming.
All
of
them
are
perfect
and
all
of
them
make
the
very
best
decision.
R
Every
single
time
I
will
I
won't
ever
do
that.
What
I
will
say
is
that
99
of
our
providers
are
doing
the
very
best
they
can.
They
don't
have
nefarious
intent,
they're
not
trying
to
skirt
rules,
they're
really
just
trying
to
survive
and
do
what
they
believe
was
their
calling,
which
is
healing
people,
and
so,
when
you
make
decisions
about
legislation,
remember
that
we
can
get
in
the
weeds
to
try
to
to
mitigate
any
opportunity
for
a
bad
actor
to
find
a
loophole.
R
R
But
there's
more
risk
in
creating
policy
to
try
to
go
after
the
very
small
percentage
of
Bad
actors
and
in
doing
so
doing
a
great
deal
of
harm
to
the
majority,
who
are
good
actors,
and
so
I
would
just
offer
that,
in
terms
of,
if
your
physician
stories
of
you
know
I,
don't
know
what
the
example
is
a
dermatologist
using
Botox
the
way
they
shouldn't
or
whatever
it
is
I
won't
tell
you
that
that
doesn't
exist.
I.
Would
that
would
be
disingenuous?
R
B
T
You
Mr
chairman
Ms
Bush
on
the
issue
of
24
hours
versus
120
hours
versus
five
business
days,
wouldn't
taking
it
to
120
hours,
potentially
deprive
basically
to
potentially
two
days
worth
of.
T
You
know
a
weekend
that
would
take
into
effect
a
weekend
if
you
did
the
five
business
days.
I
understand
the
you
know
the
24
verses,
120
or
72,
whatever
you
end
up
with,
but
doesn't
that
potentially
take
away
from
the
time
frame?
Let's.
B
R
Chairman
I
think
what
we
intend
and
I
was
probably
not
clear,
so
I
apologize.
Let's
talk
first,
just
about
urgent,
so
for
Urgent
right
now,
the
bill
before
you
has
a
24-hour
timeline
and
it
further
states
that
if
the
24-hour
timeline
is
not
met,
the
request
is
automatically
approved.
Okay
insurance
has
said:
that's
untenable.
We
really
we
really
are
uncomfortable.
We
can't
move
forward
with
that,
and
so,
as
part
of
a
compromise
we've
said.
R
Okay,
then,
instead
of
24
change,
that
number
to
72
for
Urgent
and
72
has
been
our
like
our
our
limit
so
separate
from
that
conversation,
so
urgent
is
24
to
72.
Yes,
it's
longer
to
your
point,
it's
a
compromise
that
we're
sympathetic
to
the
you
know,
burden
that
that
would
create
for
our
payers
and
we're
trying
to
we're
really
trying
to
be
good
players
so
separate
from
that.
Then
you
have
non-urgent
right
now.
R
So
it's
hours
throughout
and
say
then
it's
120
hours
for
non-urgent
requests,
meaning
it
doesn't
matter
if
it's
a
holiday,
it
doesn't
matter
if
it's
Saturday
it's
120
hours.
That's
the
expectation.
Everybody
knows
it.
It's
ours
which
is
consistent,
and
so
that
I
don't
know.
If
that
isn't
am
I
helping
your
face
says:
I'm,
not
helping.
T
You
Mr
chairman,
I
I,
think
you
got
there
but
yeah
the
the
holidays.
I
can
see
that
being
a
problem.
Yeah
like
I,
understood
most
your
rhetoric
going
into
that,
but
I
see
the
the
the
the
loss
of
of
time
to
get
this
done,
and
you
know
quite
often
often
the
carriers
just
simply
aren't
doing
business
on
those
days.
Foreign.
R
Representative
Chadwick
you're,
correct
I,
mean
in
in
a
Utopia
that
Physicians
create
there
isn't
prior
authorization
right,
and
so
it's
all
a
delay
of
some
kind.
They
don't
want
to
wait
any
amount
of
hours,
that's
not
reality,
and
prior
authorization
has
a
utility.
It
has
a
purpose
and
we're
not
here
to
tell
you
that
it
should
go
away
completely,
even
though
I
do
believe
that
it
is
like
the
Utopia
that
it
doesn't
exist,
we're
living
in
a
landscape
where
it
has
a
purpose
in
good
faith.
R
I
hear
what
you're
saying
and
that
it's
a
delay
and
it's
ours,
and
we
agree
so
yes
and
we're
trying
to
do
right,
and
so,
if
prior
authorization
is
going
to
persist,
which
it
will
we'd
like
the
timeline
to
be
consistent,
we
would
like
it
to
be
ours
not
once
sections
days
if
it's
a
certain
procedure
and
this
one's
hours,
if
it's
a
different
kind
of
procedure,
let's
be
clear,
let's
be
transparent,
just
because
other
states
have
it
five
days
and
72
hours
doesn't
mean
it's
right.
U
Morning,
everybody
Josh
hanis
with
the
Wyoming
Hospital
Association,
so
just
want
to
make
a
a
few
sort
of
broad
points
about
the
the
current
environment,
along
with
some
specifics
about
the
bill.
U
Obviously
we
we
asked
for
this
to
come
forward
and
we
we
support
the
the
pieces
that
have
been
included
in
the
draft
before
you
and
we
have
participated
in
several
discussions
with
different
insurance
providers
and
their
representatives
and
we're
and
we're
far
apart
and
I,
think
you
heard
from
Blue
Cross
Blue
Shield
that
that's
just
part
of
the
inherent
tension
in
these
conversations,
but
if
I
could
I'd
like
to
just
from
our
perspective,
offer
and
hopefully
you'll
consider
this
as
well.
U
As
you
know,
what
is
the
role
of
insurance,
and
what
we
would
say
is
that
the
role
of
insurance
is
to
Simply
pay
health
care,
Bills
full,
stop
the
the
treatment
decisions
and
and
and
care
plans
that
are
created
should
be
between
a
patient
and
a
doctor
and
and
currently
and
as
you've,
already
heard,
that
insurance
creates
and
places
a
ton
of
burden
on
providers
to
jump
through
hoops
to
deliver
the
care
that
they
think
is
best
for
patients,
and
we
think
that
that
power
Dynamic
needs
to
change
So.
U
Currently,
insurance
companies
can
deny
claims
right
through
prior
authorization.
They
can
deny
coverage.
If
you
don't
pay
premiums,
you
don't
get
insurance.
Conversely,
in
a
hospital
situation,
everybody
who
walks
into
our
facilities
gets
treated
regardless
of
their
ability
to
pay.
If
they
don't
have
insurance,
they
can't
pay,
they
don't
and
we
eat
it,
and
that
comes
out
to
about
120
million
dollars
a
year
across
the
state
where
a
significant
part
of
the
social
safety
net
and
we're
proud
to
do
it.
U
But
these
this
administrative,
this
additional
work,
adds
to
that
burden
and
it
makes
it
very
difficult
for
us
to
deliver
promises
to
our
community
to
care
for
people
that
maybe
don't
have
money
or
insurance
coverage.
Insurance
coverage
is
a
great
thing,
but
we
think
there's
things
in
it
that
need
to
change.
U
I
would
ask
you
to
consider
also
when
they
talk
about
managing
costs.
That's
a
worthy
goal.
If
you
believe
that
the
money
that
you
pay
in
premiums,
so
their
revenues,
premiums
and
what
they
don't
spend
is
profit
and
they
do
a
splendid
job
of
maintaining
that
you
have
insurance
companies,
small
ones
who
post
tens
of
millions
of
dollars
a
year
up
to
larger
companies
that
post
billions
a
quarter
so
whose
cost
are
they
managing
the
the
argument
that
hospital
charges
drive
cost
is
really
puzzling
because
we
operate
on
thin
to
negative
margins.
U
B
V
You
Mr
chairman
committee
members,
Eric
bulleth,
while
I'm
an
Hospital,
Association
and
I
won't
belabor.
This
point,
however,
the
reason
this
bill
is
before
you
is
because
this
is
one
of
the
biggest
issues
that
our
members
face.
We
represent
28
hospitals,
those
hospitals
employ
a
tremendous
amount
of
physicians,
physical
therapists,
x-ray
lab,
all
of
which
are
required
to
do
pre-authorization
and
I
think
it
was
great
that
you
were
able
to
tour
a
hospital
yesterday.
V
Brand
new
hospital
who's
been
open
for
only
a
few
months
and
they're
already
in
the
middle
of
this
prior
authorization
issue
and
they've
had
to
add
staff
to
be
able
to
get
their
bills
paid.
I
I
think
that
one
of
my
favorite
books
is
the
the
art
of
the
deal,
and
we
have
tried
to
be
collaborative
in
our
approach
to
this.
V
We
have
involved
the
stakeholders
and
we
didn't
pull
any
punches,
but
we
didn't
hide
the
fact
that
we
were
very
open
that
we
were
going
to
bring
this
as
a
topic
and
I
think
that
we're
in
a
pretty
good
place
right
now,
no
one's
winning
100.
We
we
do
have
compromise
in
here
and
we've
offered
again
we've
offered
compromise.
We
met
with
Blue
Cross,
Blue
Shield,
and
the
timeline
for
these
pre-authorizations
seems
to
be
a
problem.
V
So
in
our
comments
in
July,
we
offered
72
hours
and
was
five
days
or
120
hours,
I,
don't
care
which
way
it
goes
not
business
days
but
days,
but
in
exchange
for
that,
we
wanted
to
keep
the
peer-to-peer
before
there's
a
not
denial.
We
wanted
to
give
them
the
time
to
make
sure
that
their
physician
could
talk
to
our
provider
and
make
sure
that
the
denial
really
should
take
place
I'm
with
with
Sheila
and
with
Josh.
V
On
this,
though,
at
what
point
did
the
insurance
companies
start
prescribing
and
treating
they
shouldn't
be
doing
that?
That's
why
we
have
trained
professionals
and
they're
they're
being
questioned
on
almost
everything
they
need
to
do.
They
have
to
jump
through
hoops
to
get
those
paid.
I
listened
to
Senator
Baldwin
talk
about
changes
in
in
Pharmaceuticals,
that's
step
therapy.
That's
it's
a
great
example
of
how
we
drive
costs
down
and
how
we
try
other
things
and
actually
especially
on
step
therapy,
really
doesn't
work.
V
A
lot
of
times
we
end
up
going
through
step
therapy,
and
then
we
end
up
doing
whatever
needed
to
be
done
after
the
fact.
When
we
delayed
care
to
these
patients,
we
obviously
have
issues
and
we're
concerned
about
payment.
More
importantly,
we're
concerned
about
the
patient
experience
and
getting
patient
care
as
quickly
as
possible
and
taking
care
of
those
patients.
V
V
Why
they're
denied
so
I
think
that's
a
really
very
important
part
of
this
bill
is
that
we're
able
to
get
that
that
data,
so
that,
if
we
need
to
make
changes,
we
can
do
it
and
so
I
really
think
that
that's
important
the
administrative
burden
so
I
just
want
to
talk
about
this.
We're
hospitals
are
the
most
highly
regulated
industry
in
the
country.
I
think
fa,
FAA
and
banks
are
probably
close,
but
we
continue
to
add
costs
to
the
system.
V
Mr
mincy
talked
about
the
staff
that
they've
added
they've
got
RNs
that
are
spending
75
percent
of
their
time
on
issues
like
this
and
we're
in
the
middle
of
a
staffing
shortage
right
now,
where
we
can't
get
enough
RNs,
we
can't
get
enough
LPNs
they're
spending
time
doing
that
instead
of
caring
for
patients
and
there's
really
no
reason
for
that,
I
think
I
think.
Finally,
the
gold
carding
issue
I
think
it's
super
important
I.
V
V
We
talked
about
this
early
on
so
Medicare
Advantage
plans,
which
we
talked
about
yesterday,
while
we
were
at
the
new
hospital
Medicare
Advantage
plans
are,
are
taken
care
of
by
Cigna
and
there's
a
there's
actually
lawsuits
going
on,
there's
all
kinds
of
things
going
on
nationally,
because
one
of
the
things
they
do
automatically
is
they
deny
those
claims
and
then
they
have
to
jump
through
hoops.
Our
providers
have
to
jump
through
hoops
to
get
those
those
denials
reconsidered
and
then
80
of
those
are
overturned
and
they're
paid
after
you
jump
through
those
Hoops.
V
Why
do
we
need
to
do
that?
Mr
Spencer
will
tell
you
that
this
isn't
done
to
contain
costs
and
maybe
for
Mountain
Health,
that's
not
the
case,
but
as
a
principal
as
a
whole.
It
is
what
is
used
by
insurance
companies
to
slow
down
the
payment
of
claims
or
to
not
pay
them
at
all.
So
I
think
this
is
a
very
common
sense
approach.
I
think
it's
well
thought
out.
I
think
we've
done
a
lot
of
good
work
on
this
and
I.
V
You
know
we're
happy
to
make
the
concessions
that
we've
talked
about
as
far
as
timeline
I
think.
Overall,
we
have
a
very
good
product
that
we
have.
All
all
of
us
have
worked
on
and
we've
come
up
with
with
what
I
think
is
a
very
good
solution
in
the
state
of
Wyoming.
The
last
thing,
though,
that
I
would
say
and
I'm
concerned
and
and
in
all
honesty
this
only
captures
a
couple
of
our
insurance
companies
in
the
state.
F
V
R
Mr,
chairman
Senator
doc,
stetter
I'm,
happy
also
I
appreciate
the
work
I
do
want
to
be
very
genuine
in
the
compromise
that
was
constructed
on
the
timeline.
R
I
think
if
we
walk
away
without
addressing
some
of
those
concerns,
I
I
will
personally
probably
have
not
done
my
job
as
well
as
I
could
have,
and
so
I
think
that's
important,
but
I'm,
happy
I,
I,
don't
disagree
with
Mr
bowley's
interest
and
sentiment
around
the
state
plan
and
those
35
000
lives.
I!
Don't
know
that
if
that
you
can
pull
it
in
today,
I
also
don't
know
how
you
pull
it
in
today.
R
R
But
if
you
don't
address
that
today
in
this
bill
we
are
happy
and
we
appreciate
this
work
and
we
think
it's
a
good
product.
Thank.
F
U
Mr
chairman
Senator
docs
that
are
clearly
I
agree
with
Eric
I,
think
it's
a
practical
matter.
The
the
state
employees
plan
and
trying
to
move
that
plan
underneath
this
legislation
would
need
to
be
done
in
a
separate
either
bill
or
rule
making
anyway.
So
we're
happy
to
move
forward
with
this,
as
is,
and
we
can
work
on
the
other
issues
separately.
Thank
you.
Thank
you.
Mr
chairman.
B
L
You
Mr
chairman
one
thing
that
I
just
wanted
to
run
past
you
when
I
was
looking
through
again
when
originally
when
we
went
from
the
model
legislation,
there
was
a
definition
on
so
our
def
look
at
page
five
definitions
of
medically
necessary
Health,
Care
Services.
Initially
there
was
a
definition
in
that
model,
legislation
that
we
were
going
with,
and
it
was
an
lso
suggestion
that
we
go
with
the
what
is
in
statute
and
we
kind
of
made
that
decision
to
go.
L
Reads
that
medically
necessary
Health
Care
Services
means
healthcare
services
that
a
reasonable
physician
would
provide
to
a
patient
for
the
purpose
of
preventing,
diagnosing
or
treating
an
illness,
injury,
disease
or
symptoms
in
a
manner
that
is
in
accordance
with
generally
accepted
standards
of
Medical,
Practice,
clinically
appropriate
in
terms
of
type
frequency
extent,
site
and
duration.
L
And
then
three,
not
primarily
for
the
economic
benefit
of
Health
clients.
Does
that
cause
you
any
angst
to
just
go
back
to
that
original,
a
little
more
basic
definition.
B
R
That
said,
I
don't
remember
exactly
what
the
conversations
were
involving
the
change
and
so
because
I
can't
think
of
those
right
now
and
I
might
not
be
able
to
articulate
how
the
change
happened.
I
don't
want
to
make
a
statement
that
I
will
later
regret.
R
So
I
don't
know,
but
I
think
we
were
fine
with
either
and
our
members
haven't
had
a
problem
with
this
one.
Either.
V
Mr,
chairman
representative
Penn
I,
if
I
remember
as
part
of
the
compromise
and
I
think
it
was
also,
we
were
trying
to
to
have
statutes
match
up
with
with
the
same
definitions.
I
think
we're
fine,
either
way
but
I
think
going
back
to
Senator
Doc's
theater's
question.
We
do
like
the
bill
the
way
it
is,
but
we're
also
willing
to
compromise
on
the
timeline
as
long
as
we
keep
the
peer-to-peer
intact
and
and
make
that
available
for
our
members
and
for
the
insurance
companies
to
be
able
to
comply
with.
J
Thank
you,
Mr
chairman,
a
question
to
any
of
you
page
six.
There's
line
33
start
talking
about
medications
for
opioids
use
disorder
with
the
working
task
group.
Do
you
guys
remember
how
that
can
you
give
us
some
insight
on
how
that
got
added
into
this
bill?
The
history
behind
that.
U
J
My
fear
here
is
that
over
time,
things
are
going
to
change
in
medicine
medications
used
for
opioid
disorder
will
change
I'm,
just
not
sure
how
this
got
added
in.
If
we
need
to
be
this
specific
in
this
in
this
bill,
Miss.
R
There
Mr
chairman
representative,
Claussen
I,
believe
that
the
the
intent
and
the
motivation
behind
that
inclusion
is
if
someone
is
suffering
from
a
substance,
use
disorder
and
they
present
with
an
interest
in
in
receiving
treatment
or
getting
better
or
healing.
R
You
have
to
strike
very
quickly
because
there's
so
much
involved
and
so
many
layers
to
addressing
that
particular
condition
in
a
timely
fashion.
So
if
a
person
has
hit
rock
bottom
as
we've,
sometimes
you
know
as
Layman.
We
talk
about
someone
hits
rock
bottom
or
they've
really
come
to
a
point
where
something
significant
has
happened
in
their
life
that
has
motivated
them.
R
Don't
know
because
again
page
six
is
the
definition
and
I
can't
find
on
the
Fly,
where
it
is
codified
that
the
that
it
doesn't
require
prioritization,
but
I
think
the
intent.
Is
that
something
that,
regardless
of
what
the
treatment
is
and
regardless
of
what
the
advances
or
thanks
so
yeah
it
just
it
just
says,
no
Health,
insurer
or
contracted
utilization
review
entity
shall
require
prior
authorization
for
the
provision
of
medications
for
opioid
use
disorder.
R
So
I
think
it's
broad
enough
that,
as
that
changes
to
your
point
and
as
medicine
shifts
or
advances,
I
think
that
it
still
covers
it,
because
it's
not
prescriptive
or
specific.
It
just
says
that
the
treatment
of
substance
use
disorder
and
whatever
McCain
medications
associated
with
that
treatment,
are
not
going
to
be
subject
to
a
prior
authorization
requirement.
B
Okay,
we'll
get
you
out
the
hot
seats
for
now.
Let's
go
about
a
number
of
minutes.
Until
we
take
a
break,
do
you
do
anything
on
prayer
off?
You
don't
have
to
you're
good
nursing,
hey
Jason
I'm,
just
not
yeah!
It's
not!
Every
day
we
see
a
telecommunications
lobbyist
on
a
prior
auth
build,
but
welcome
to
labor
health.
W
Thank
you,
Mr
chairman
members
of
the
committee,
Jason
Hendricks,
yes,
I
am
in
the
Telecommunications
industry,
Broadband
provider,
we're
a
small
provider
through
a
number
of
areas
of
the
state.
Our
concern
with
this
bill
is
that
we're
we're
on
a
self-funded
plan
through
the
association
that
we're
part
of
and
so
I.
You
know,
I
guess
my
my
as
I
read
this
bill.
I.
Don't
think
that
there's
an
exemption
here
for
self-funded
plans
and
I,
don't
think
that
this
is
Exempted
anywhere
else.
W
So
with
that
as
a
as
a
background,
what
kind
of
go
with
our
concerns?
So
so
again
you
know.
So
we
we
are
part
of
ntca
ntca
is
an
association
of
850
or
so
rural
Broadband
providers
across
the
country
of
that
there's
a
subset
that
are
part
of
the
group
health
plan
of
ntca
and
for
us
specifically,
you
know
since
each
place,
since
each
plan
has
to
be
State
specific,
we
are
the
only
provider
in
Wyoming.
W
That's
part
of
that
that
plan
for
for
ntca,
so
our
concerns
with
anything
that
would
happen
here
that
would
cause
insurance
rates
to
go
up,
would
impact
our
ability
to
provide
Assurance
to
our
employees
and
take
away
from
our
ability
to
actually
provide
Broadband
where
it's
needed,
which
is
what
our
real
goal
is,
so
that
that's
that's
the
main
concern
and
I
think
that
the
generally
there's
there
is
an
exemption
for
self-funded
plans
on
for
for
state
law,
and
so
our
our
recommendation
would
be
that
there
be
an
exemption
for
for
self-funded
plans
in
this
in
this
bill.
W
Two
of
the
specific
concerns
that
we
have
on
the
bill
and
they're
quite
a
bit,
but
two
of
the
bigger
ones
are
the
gold
plating
specifically
I,
think
that
provides
potentially
some
loopholes
down
the
line,
some
some
bad
incentives
with
it.
That
would
be
problematic
and
then
some
of
the
provisions
on
timelines
are
are
inconsistent
with
what
we
do
under
erisa
for
the
time
frame.
So
they're
a
bit
tight.
So
there's
the
added
requirements
of
what
has
to
be
done
before
a
claim
is
denied.
W
But
then
there
are
shorter
time
frames
and
so
that
pinch
seems
to
be
pretty
problematic
for
our
insurance.
So
so
that's
that's.
Basically
it
I
think
that
we,
you
know
we
do
a
good
job
of
providing
a
good,
a
good
benefit
to
our
employees.
We
pay
a
a
pretty
high
fixed
percentage
of
what
their
premiums
would
be.
W
They
pay
a
smaller
percentage
and
so
the
way
that
this
would
work
if
there's
any
additional
costs
directly
because
of
the
what
they
have
to
do
internally
to
comply
with
this
law
or
there's
increased
costs,
say
10
of
our
employees.
All
of
a
sudden,
because
this
this
law
is
passed
they're
now
higher
costs
associated
with
our
service.
So
our
premium
goes
up
because
of
the
additional
it's
it's
potentially
twice
hitting
us
with
cost
increases
and
the
way
the
fixed
percentage
would
work
for
what
we
provide
for
insurance.
W
There
would
be
the
direct
impact
on
the
employees
of
what
they
would
have
to
pay
for
the
difference
so
kind
of
a
different
issue,
different
angle,
from
what
you
guys
are
hearing
but
I
hope
hope.
That's
clear
what
I'm
saying
this
isn't
my
normal
issue.
So
thank
you
for
the
time
and
stand
for
any
questions.
Okay,.
F
W
W
So
if
there's
a
it's
a
small
group
of
people,
so
if
they
have
to
do
different
compliance
for
Wyoming
versus
other
states,
that
is
a
direct
cost
specific
to
Wyoming,
and
since
we
are
the
only
company
on
that
plan,
that's
a
direct
cost
that
would
come
right
to
us
and
so
and
then
the
other
part
of
it
was
if
there
are
additional
medical
procedures
that
are
costly
compared
to
current
procedures.
W
And
that's
really,
you
know
from
from
my
understanding-
lay
understanding
medical
Necessities
medical
necessity
relative
to
what
well
relative
to
the
current
procedures.
So
now,
if
there's
a
higher
cost
procedure,
say
10
times
as
much
as
something
that's
pretty
comparable.
That
would
seem
to
me,
like
those
employees
that
take
advantage
of
that
would
cause
more
costs
for
our
plan,
which
would
then
get
passed
on
to
us
since
we
aren't
the
only
entity.
Thank
you,
Mr
chairman.
F
B
Right,
thank
you
for
being
here.
Thank
you.
So
it's
been
good
to
come
to
Saratoga
anyone
else
in
this.
The
room,
Tony
Melinda,
welcome.
X
X
Melinda
Carroll
representing
the
Wyoming
Pharmacy
Association
issues
that
had
been
brought
up
previously
with
the
questions.
Pharmacy
does
see
prior
authorizations
quite
a
bit
as
well,
and
we
do
try
and
communicate
with
providers
as
soon
as
possible
when
we
see
those
denials
and
really
try
and
work
with
them
to
find
what
is
best
for
the
patients,
and
so
that
is
one
thing
as
for
increasing
costs,
prior
authorization
bills,
I.
Don't
think
that
those
costs
have
been
borne
out
in
any
of
the
other
states
that
have
passed.
X
Legislation
such
as
this,
and
there
are
plenty
of
studies
out
there
that
actually
have
shown
that,
while
prior
authorization
requirements
have
reduced
cost
of
the
health
care
costs
that
they're
targeted
at
overall
costs
have
not
been
reduced
by
it.
And
so
it
would
be
questionable
to
say
that
overall
costs
would
increase
if
prior
authorization
legislation
would
be
implemented
in
the
state.
X
So
with
that,
I
will
go
to
my
prepared
statement.
The
Wyoming,
Pharmacy
Association
portfolio
supports
the
efforts
to
implement
prior
authorization
legislation
in
our
state.
We
stand
with
the
Wyoming
Medical
Society
in
recognizing
that
this
is
a
critical
patient
access
and
Care
issue
and
would
encourage
the
committee
to
consider
amendments.
The
medical
society
has
recommended
I
have
witnessed
firsthand
the
challenges
that
prior
authorizations
requirements
pose
to
both
patients
and
health
care
providers.
X
These
requirements
often
lead
to
delays
in
patient
care,
administrative
burdens
and
increased
health
care
costs.
Having
legislation
that
streamlines
and
standardize,
the
prior
authorization
process
can
ensure
that
patients
receive
timely
access
to
medications
and
treatments
they
need,
while
reducing
administrative
burden
on
health
care
providers.
X
We
are
dedicated
to
working
towards
reforms
that
prioritize
patient
well-being
over
insurer
profits.
It
is
instead
essential
to
strike
a
balance
between
Cost
Containment
and
ensuring
timely
and
appropriate
access
to
Essential,
Health,
Care,
Services
and
medications
for
all
patients,
and
with
that
I
would
stand
for
questions.
B
Board
of
Pharmacy
have
anything
on
that
side
of
the
room.
Looking
not
Mr,
Hayes
welcome
and
then
after
Ralph
will
probably
take
a
10
minute
break.
I
know
we
have
two
people,
maybe
three
people
online,
who
also
want
to
jump
in
on
this
and
then
we'll
try
to
get
through
all
the
public
comment
no
later
than
10
50..
But
with
that
welcome
Mr,
Hayes
closures,
Mr.
Q
Chairman
members
of
the
committee,
my
name
is
Ralph
Hayes
I'm,
the
manager
of
the
employees
and
officials
Group
insurance
program.
Since
we
had
the
issue
come
up,
I
thought
I
would
step
up
here
now
remember.
This
pre-authorization
is
really
aimed
at,
of
course,
insurance
companies,
and
it
also
includes
third-party
administrators.
So,
while
the
state
plan
is
not
specifically
mentioned
in
here,
the
fact
that
we
utilize
a
third
party
administrator
automatically
makes
this
an
impact
to
the
program.
Q
Now
I've
been
doing
this
for
a
long
time,
41
years
and
I'm
in
a
unique
position
because
we're
a
self-funded
medical
plan,
I
used
to
work
on
the
insurance
side,
I
see
the
bills,
I
know
what
happens
and,
as
you
know,
pre-authors
in
the
place
because
of
the
bad
players
out
there
and
I.
It's
not
necessarily
bad
players
per
se,
but
the
burdens
come
out
because
there
are
certain
players
out
there
who
shall
we
say
want
to
maximize
things
and
I'm
going
to
give
you
some
examples.
Let's
take
a
look
at
Orthopedics
right.
Q
We've
got
some
Orthopedic
groups
in
this
state,
I've
seen
them
the
when
somebody
a
patient
goes
to
them.
The
knife
is
always
the
answer,
while
another
Orthopedic
Group
wants
to
go
through
step
therapy,
this
this
try
this
first
and
then
from
this
first
so
which
one
do
you
think
we
probably
want
to
do.
The
most
pre-auth
with
and
Orthopedic
procedures
can
be
very
expensive,
especially
when
you
start
getting
into
back
fusion
when
it's
not
called
for
there.
Isn't
it
doesn't
meet
the
medical
criteria?
Q
Q
Q
Oh,
let's
see
3
30.
on
Friday
and
we
have
a
holiday,
so
they
just
barely
got
it
everybody's
going
home
at
five
o'clock,
so
you're
Saturday
Sunday,
it's
a
Monday
holiday
you're
out
already
out
of
compliance
and
let's
talk
about
the
120
hours.
So
you
take
away
48
hours
for
a
weekend
same
scenario:
Monday
holiday.
That
leaves
one
day
for
a
non-urgent.
Q
Priyath
now
I
got
to
tell
you
most
important
non-urgent
Prius
aren't
something
that's
going
to
be
scheduled
the
next
day.
Those
things
are
scheduled
out
much
farther
in
the
down
the
road
to
get
taken.
Care
of
I
can't
even
get
to
see
my
doctor
and
generally
one
two
weeks
trying
to
make
an
appointment,
so
I
do
have
a
little
bit
difficulty
understanding
why
we
need
120
hour
for
non
-urgent
pre-authorizations
and
that's
from
a
standpoint
of
a
plan
administrator
on
a
self-funded
plan.
Q
Q
I'm
kind
of
in
the
middle
of
this
one,
I
I,
agree
with
some
with
the
medical
society.
I
agree
some
with
the
insurance
companies,
but
we
are
impacted
by
both
of
them,
but
the
timeline
issue.
I
guess
I
do
see
140
hours
five
days,
the
same
issue
that
we
talked
about
for
delaying
that
care
for
the
time
frames
with
a
holiday
gives
the
insurance
companies
virtually
no
time
when
maybe
they
should
be
dealing
with
the
Urgent
one.
Q
That
needs
to
a
more
immediate
decision.
How
do
you
prioritize
that
on
a
Tuesday,
when
you
only
have
roughly
seven
hours
to
get
that
completed
because
of
the
time
frame
that
was
submitted,
and
that's
the
only
question
comments
that
I
have
on
this
particular
one
understand
for
any
questions
that
you
might
have.
J
Q
B
B
Oh
all
right
committee,
as
we
settled
back
in
from
our
seven
minute,
13
minute
break,
we
have
a
couple
of
people
online
who
want
to
testify.
Y
Thank
you
good
morning.
Thank
you.
Co-Chairman
and
members
of
the
committee.
I
really
appreciate
the
opportunity
to
provide
comments
to
you
this
morning.
I
really
appreciate
the
opportunity.
Thank
you
for
letting
me
do
it
remotely
I
really
appreciate
it.
My
name
is
Carly
tebe
I'm,
the
regional
director
for
America's
health
insurance
plans.
Ahip
is
the
National
Association
that
represents
health
insurance
providers
and
just
wanted
to
share
some
quick
comments.
Y
I
know
you're
trying
to
get
through
public
comments
quickly,
but
we
we
really
appreciate
the
sponsors
willingness
to
work
with
us
on
the
bill
appreciate
the
changes
that
have
been
made
thus
far.
Ahip
does
have
two
key
significant
concerns.
Y
One
is
the
timeline
around
urgent
services
and
appreciate
the
comments
from
the
medical
society
about
their
willingness
to
move
to
72
hours.
Ahip
would
also
make
that
request
for
that
change.
So
really
appreciate
the
dialogue
on
that
and
consideration
of
that
change
are
other
really
significant.
Concern
with
this
legislation
is
section
5513
on
the
gold
carding
piece.
This
section
creates
a
mandatory
gold
carding
program.
We
have
significant
concerns
with
this
provision.
Y
Prior
authorizations
only
used
in
limited
circumstances,
and
it's
intended
to
help
lower
patients,
out-of-pocket
costs,
protect
patients
from
overuse
or
misuse
and
unnecessary
treatments
and
ensure
that
care
is
consistent
with
evidence-based
guidelines.
There
is
a
significant
amount
of
waste
and
unnecessary
treatments
in
our
system,
and
this
is
supported
by
academic
research
and
unnecessary
treatments
can
be
associated
with
Adverse
Events,
and
so
we
do
have
a
lot
of
concerns
that
this
provision
is
going
to
create
significant
patient
safety
concerns.
Y
The
threshold
for
80
percent
of
for
a
provider
to
prayer
authorization
exemption
with
an
80
threshold
is
extremely
low.
This
means
that
20
of
theirs
of
the
Care
could
still
be
fraudulent
or
unnecessary,
and
it
doesn't
get
that
you
know
the
necessary
oversight
to
ensure
that
is
appropriate
and
it's
safe
for
the
patient.
Y
I'd
also
like
to
note
that
this
section
in
particular,
is
based
on
a
law
that
passed
in
Texas
in
2021,
and
that
law
had
an
effective
date
of
January
1
2022,
but
it
is
still
in
the
initial
stages
of
rulemaking.
It
has
turned
out
to
be
required,
extensive
rule
making,
and
it's
been
an
extremely
heavy
lift
for
the
state
to
implement,
and
it's
also
estimated
to
be
a
significant
cost
driver
for
premiums
in
the
fully
insured
Marketplace
in
Texas.
Y
We
have
estimates
that
it's
going
to
increase
premiums
by
a
billion
dollars
annually,
so
we
do
have
really
strong
concerns.
As
I
said,
with
this
section,
I
don't
think
it's
appropriate
to
have
a
mandatory
gold
carding
program
implemented.
Do
you
think
it
will
increase
costs
in
Wyoming
and
will
be
counter
to
the
goals
that
you're
trying
to
solve
with
this
legislation?
So
with
that,
I
will
wrap
up
I'm
happy
to
answer
any
questions,
but
really
I
appreciate
the
opportunity
to
provide
comments.
This
morning.
B
Certainly
thanks
for
welcome
awaiting
questions
from
the
committee
I'm,
not
seeing
any
Carly,
so
thank
you
for
being
with
us
have
a
great
rest
of
your
Friday.
B
Next
Miss
Hermann
Marguerite
welcome
to
labor
health
closures.
Thank.
Z
You
Mr
chairman
Margaret
Herman
I'm
speaking
today
as
a
consumer
representative
for
the
National
Association
of
insurance,
Commissioners
and
the
consumer
reps
have
focused
on
this,
along
with
the
AMA
as
an
area
that
needs
attention
and,
first
let
me
Express
great
sadness
at
not
being
in
Saratoga
this
morning,
I'm
stuck
in
Cheyenne.
Z
First
of
all,
I
would
like
to
say
that
you
don't
need
to
demonize
the
insurance
companies
to
really
find
to
define
a
need
for
better
efficiency
in
the
pre-authorization
and
really
fix
problems,
so
I
hope
nobody
goes
there
and
I
haven't
heard
it
so
far
today,
to
a
great
extent,
so
I
hope
that's
where
we
are
some
of
these
requirements
in
the
bill
which
I
do
support
in
general,
is
going
to
require
some
business
changes
by
insurers
in
Wyoming.
So
so
it
does
impact.
Z
You
know
that
they're,
like
friends
and
Staffing
and
Staffing
during
holidays,
the
time
limit
thing
so
understanding
that
there's
going
to
be
some
investment,
there's
going
to
be
some
cost
on
their
part.
That
needs
to
be
recognized
as
part
of
this
package.
Z
I
will
say
that
where
I'm
coming
from
is
how
does
this
affect
consumers?
The
enrollees
is
the
term
used
in
the
statute
and
otherwise
insurance
company
called
rate
payers,
but
the
same
thing:
it's
the
person
who
has
really
the
greatest
stake
and
and
that
this
system
work
and
work
well
and
be
efficient,
but
also
not
not
cause.
Z
Well,
we
just
heard
from
ahip.
You
know
that
there's
waste
and
I
I
guess
I'm,
not
com.
Convinced
of
that.
But
that's
the
stake
is
not
is
Health.
It's
cost
it's
efficiency,
and
so
I
would
kind
of
I
would
like
this
process
to
include
the
consumers
and
all
discussions
going
forward.
Z
Z
If
that's,
how
you
want
to
think
of
them
so
and
and
to
that
end,
I'm
I
really
appreciate
the
data
Gathering
they're
required
in
this
bill,
so
that
we'll
find
out
instead
of
anecdotes,
which
are
plentiful
as
we
all
know
that
find
out
is,
is
a
pre-authorization
working,
we'll
and
then
we'll
find
out.
Z
The
changes
made
by
the
statutes
and
regulations
is
that
working
to
make
the
system
efficient,
quick,
responsible,
responsive
and
I,
would
you
know
it
should
say
the
number
of
denials
for
what
reason
the
appeals
do?
People
know
how
to
pursue
appeals?
Do
they
just
give
up
and
go
away
which
we
have
some
data
that
that's
what
happens
to
Consumers?
They
find
the
whole
system
just
beyond
their
ability
to
deal
with
it,
especially
when
they're
sick,
and
so
so
so
we
have
to
make
pre-authorization.
Z
If
we're
going
to
have
it,
we
have
to
make
it
work
and
is
it
saving
money?
What
is
the
return
on
the
investment
of
this
process?
Does
it
actually
increase
cost
does?
Does
it
save
money,
and
and
most
of
all,
that
does
it
improve,
improve
care
and,
as
we
all
know,
getting
the
right
care
is
important,
but
getting
at
the
right
time
is
is
just
as
important.
Z
Just
real
real
briefly
I
will
say.
The
concerns
of
the
consumers
and
consumer
groups
is
that
the
current
system
is
cumbersome.
It
creates
delay
in
poor
health
outcomes
or
it
can
and
there's
a
national
Patient
Advocate
Foundation
survey
that
45
percent
of
respondents
report
delays
in
filling
prescriptions
because
of
pre-authorization
Step
therapy
or
quantity
limits.
The
M.A
reports
that
Physicians
report
burden
of
time
and
staff
and
delay
because
of
pre-authorizations,
which
you
heard
amply
this
morning
and
insurance,
has
complain
about
deficiencies
in
data
reporting
and
other
major
concerns.
Z
There's
a
wide
variation
in
lack
of
information
about
what
services
require
pre-authorization.
So
this
is
sort
of
the
transparency
piece
that
I'm,
hoping
that
this
statute
really
addresses
that
that
it
does
increase
the
burden
on
the
patient
and
provider.
Z
Again,
the
national
Patient
Advocate
Foundation
survey
found
37
percent
of
respondents
reported
in
the
past
year
that
they
expected
a
recommended
service
to
be
covered
only
to
find
out.
It
was
not
part
of
their
plan.
Z
So
that's
you
know
patient
information
and,
and
what
did
they
do
they
coped
by?
They
modified
treatment.
They
only
took
half
their
dosage
of
a
prescription,
they
went
into
debt,
they
skipped
treatment
and
they
had
no
idea
how
to
peel
so
I
think
appeals,
denials
and
the
outcome
of
that
have
to
be
part
of
the
data
collection
and
just
real
briefly.
The
the
things
that
I
think
are
important
to
be
achieved
in
this,
but
I
guess
I'll.
Just
really
briefly
mention
the
what
the
what
Sheila
Bush
mentioned
about
the
hours.
Z
Z
You
want
to
know
that
you're
going
to
find
out
and
during
the
long
holiday
weekend
that
it
may
be,
you
may
have
to
wait
several
days
for
something
that
is
not
urgent
in
the
eyes
of
some,
but
for
you
it
is,
and
and
certitude
to
the
extent
you
can
get
it
I
think
is
achieved
by
the
out
by
counting
down
in
hours.
Not
in
days
and
again,
there
are,
there
will
be
consequences
for
Staffing
and
and
how
they
do
business,
but
the
return
I
think
to
the
consumer.
Z
It's
it
makes
it.
It
makes
sense.
So
transparency
is
a
big
thing,
so
the
coverage
first
of
all
and
I
know
this
isn't
part
of
this
bill,
but
coverage
to
the
consumer.
What
requires
pre-authorization,
what
is
covered
it
all
what
is
covered?
What
requires
pre-authorization
make
it
really
plain
to
the
person,
the
consumer
who
in
fact
is
buying
the
plan.
Z
The
rate
payer
make
it
clear
to
the
patient
and
provider
a
note
notice
and
which
I
I
really
appreciate,
and
the
bill
notice
when
things
change,
when
coverage
changes
when
pre-authorization
change
and
then
give
give
them
a
chance
to
adjust
to
it.
Z
Also,
information
on
how
to
appeal
where
to
appeal
and
how
that
is
handled,
I
think
that
transparency
piece
is
important
because
you
find
consumers
at
37
percent
who
had
no
idea
what
was
coming
and
didn't
know
how
to
deal
with
it,
eliminate
a
necessary
repetition
of
reviews
and
duplicative
approvals,
efficiency
and
the
online
portal,
which
was
discussed
very
that
that
I
think
will
increase
Clarity
completeness
of
the
data
and
and
quick
response,
and
so
that
will
help
both
the
insurance
and
the
provider
and
the
and
the
in
the
consumer.
Z
Z
Z
However
verbiage
you
want
to
put
in
there
I
know
there
are
mentions
on
page
or
I
would
like
to
insert
mentions
on
page
12,
14
and
17.,
and
just
wherever
that
comes
up,
please
include
the
consumer
in
the
information
in
the
notice
and
that
sort
of
thing
and
and
the
I
know
that
there's
some
dispute
wanting
to
change
the
continuity
of
care
very
important
to
the
consumers,
so
that,
if
you
change
insurers,
there
is
a
continuity
of
care
for
three
months.
Z
While
things
get
sorted
out
when
things
get
clarified
and
then
then
obviously
the
I
don't
think
the
consumer
has
any
part
of
the
the
gold
card,
the
the
exemptions
given
to
Providers,
either
in
general
or
on
certain
services.
So
we
don't.
We
don't
really
have
anything
to
say
about
that
part,
but
those
things
that
the
transparency
is
is
extremely
important
and
including
the
role
in
all
notifications.
Z
I
would
be
asked
that
that
P
inserted
throughout
the
bill
and
that
that
is
really
the
end
of
my
comments
at
this
point.
Thank
you.
B
B
So
anyone
else
online
on
the
prior
auth,
Bill
I
know
three
of
you
are
waiting
in
white
bagging
and
two
of
you
are
just
hanging
out.
If
there
are
questions
and
then
representative
Sweeney
I,
think
you're
just
hanging
out
other
people
who
want
to
test
defend
this
bill
instead
of
the
room
x,
a
Miss
ranking,
welcome.
AA
My
name
is
Jill
reinking
I'm,
the
senior
health
policy
analyst
for
the
Department
of
Insurance.
First,
let
me
extend
an
apology
from
commissioner
Rood.
He
was
unable
to
make
it
today
and
Deputy.
Commissioner
Howard
had
a
previous
engagement
also,
so
you
get
me
the
only
thing
that
I'm
really
going
to
bring
up
everything's
been
covered
really.
Well,
obviously,
we
all
know
it's
a
Hot
Topic
and
a
lot
of
states
are
looking
at
this
I
think.
In
the
last
year,
30
different
states
have
been
looking
at
some
form
of
a
prior
auth
bail.
AA
It's
a
big
lift
and
it's
an
overall
good
purpose.
There
was
a
question
earlier
regarding
the
medical
necessity,
verbiage
and
language
that
was
in
there
and
why
it
had
been
removed.
That
was
one
thing
that
the
Department
of
Insurance
had
suggested
to
lso,
because
we
have
a
medical
necessity,
definition
underneath
the
medical
necessity
2640
102,
and
we
just
thought
it
would
cause
confusion
to
have
differing
definitions.
So
that
was
our
request
on
that
part.
AA
Another
thing
that
has
kind
of
not
been
addressed
because
it
doesn't
deal
with
really
the
providers
and
the
insurers
is.
There
is
that
component
of
reporting
and
I
did
visit
with
three
states:
New
Mexico,
Texas
and
West
Virginia,
and
it
was
in
regard
to
the
reporting
part
of
it
and
what
issues
they
had
had
with
it,
the
reporting
from
all
three
states.
They
said
that
that
became
a
very
big
burden,
receiving
the
the
reports
on
if
prior
what
prior
auth
was
denied,
why
it
was
denied
Etc.
AA
They
said
that
it
can
also
depend
on
how
they're
reporting
it
some
of
the
states
do
their
prior
authorization
based
on
CPT
codes
and
West
Virginia.
Actually
does
it
based
on
the
provider
themselves,
so
it
doesn't
matter
what
services
they've
provided.
But
if
that
provider
has
met
their
criteria
for
for
gold
carding,
then
they
they
can
do
it
with
any
service
that
they
provide.
So
it
depends.
They
said
that
it
would
depend
a
lot
on
on
how
you
were
looking
at
that
reporting.
AA
Let's
see,
another
thing
was
all
three
of
the
states
I
believe
had
to
have
a
system
developed
for
them
in
the
department
of
insurance
to
to
track
that
data
in
our
bill,
I'm,
not
sure
or
we're,
not
sure
who
would
be
tracking
that
data.
It
does
say
that
it's
provided
to
us,
but
we
don't
know
who
would
be
handling
the
initial
information
for
that
and
then
the
other
part
that
has
been
a
big
topic
today
is
the
pre-denial.
AA
The
only
request
or
thought
that
we
had
on
that
is
within
that
denial.
There's
been
a
lot
of
discussion
today
that
it's
it's
optional,
for
the
provider
to
respond
back
and
the
insurer
shall
reach
out,
but
there
are
no
timetables
in
there
and
it's
the
one
section
of
the
bill
that
when
you
look
at
it
doesn't
have
timetables
and
so
I
guess
the
question
would
be.
AA
If
we
have
that
in
there
will
you
have,
or
should
there
be
a
time
period
for
the
provider
to
respond
back
to
the
insurer,
saying
they
don't
want
to?
You
know
consult
or
if
the
insurer
doesn't
hear
back
from
them
in
a
period
of
time
that
it's
automatically
they
proceed
with
what
their
decision
is
going
to
be
I.
Think
that's
yeah.
Oh
there
was
discussion
also
about
this
urgent
review
time
period.
The
only
thing
that
would
I
that
I
would
point
out
is
in
the
department
of
insurance
rules,
chapter
63,
section
9.
AA
when
it
comes
to
expedited
reviews
within
that
section,
which
is
medical
necessity.
There
is
also
for
Urgent
situations,
a
72-hour
review
and
I'm
just
throwing
that
out
there
for
your
information.
J
Thank
you,
Mr
chairman,
thank
you
for
being
here
just
curiosity.
Earlier
this
year
we
had
heard
testimony
between
Sheridan,
Cheyenne
and
Gillette.
They
had
30
job
openings,
trying
to
deal
with
prior
authorization,
so
those
weren't
actual
employees.
Those
were
openings.
Do
we
have
any
idea
of
how
much
money
our
hospitals
in
Wyoming,
spend
dealing
with
prior
authorization?
I
won't
go
into
all
the
other
providers,
but
maybe
just
just
hospitals.
AA
You
know
chairman
swanitzer,
representative
clouston,
from
my
point
of
view.
I
do
not
know
that
information,
it's
probably
something
that
the
hospitals
or
the
hospital
associations
could
could
give
you
information
on
I'm
more
than
happy
to
reach
out,
while
we're
continuing
discussions
here
and
see
if
I
can
get
that
information
for
you.
B
But
the
question
for
the
Department
sing:
none
bless
you
all
right,
thanks,
Jim!
Thank
you!
It's
been
Saratoga
today.
All
right
and
Republic
comment.
Good
ones
gone
twice
all
right,
we'll
close
public
comments.
Committee
I
well
await
a
motion
on
the
bill.
If
anybody
wants
to
bring
one
Senator
Hutchins
is
moving
lso
68
to
be
a
2024
committee
bill.
Is
there
a
second
second
seconded
by
Baldwin
amendments
or
discussion
committee?
I
know
we've
been
provided
a
lot
today.
F
B
And
Senator
Hutchins,
second,
that
lso
that's,
can
we
call
for
an
immediate
vote
on
a
bill
and
close
discussion?
I
suppose
that's
an
order
if
the
committee
votes
in
favor
of
it
right
all
right
committee.
The
motion
is
to
make
this
a
committee
bill
without
amendments
or
further
discussion,
discussion.
B
B
M
M
A
B
All
right
committee
I
do
think
there
are
probably
some
necessary
amendments
to
be
put
on
that
bill
at
some
point
before
its
final
passage
into
law
in
Wyoming.
But
if
it
goes
to
the
house
or
the
Senate,
hopefully
we
can
spend
a
little
more
time
in
depth
than
and
maybe
all
the
parties
who
do
have
some
thoughts.
B
B
C
C
This
build
draft
contains
a
purpose
section
and
a
definition
section
starting
on
page
one
and
then
starting
on
page
four
draft
states
that
a
health
insurance,
issuer
or
Pharmacy
benefit
manager
shall
not
refuse
to
authorize,
approve
or
pay
a
participating
provider
for
providing
covered
provider
administered
drugs
and
related
Services
condition,
deny
restrict
refused
to
authorize
or
reduce
payments
for
provider
administered
drugs
when
the
administration
of
the
drug
is
a
medical
necessity
and
the
participating
provider
obtains
the
drug
from
a
pharmacy.
That
is
not
a
participating
provider
in
the
health
insurance
issue.
C
2655
104
was
added
during
the
working
group
that
took
place
in
August.
So
this
is
all
new
language
that
the
committee
hasn't
necessarily
seen
before
this
meeting.
So
in
2655,
104
Brown
bagging
is
prohibited,
started
starting
on
page
eight
and
then
health
insurance
insurance
issuers
may
require
that
providers
receive
medication
from
a
specialty.
Pharmacy
and
Specialty
pharmacies
must
give
Advanced
tracking
information
for
male
medications.
C
C
If
a
provider
administered
drug
does
not
arrive
at
the
scheduled
time
or
arrives,
damaged
or
unstable,
a
facility
may
use
its
own
stock
of
the
drug
and
shall
be
reimbursed
at
the
health
insurance
ensures
contract
of
rate.
There
is
one
conforming
Amendment
and
then
the
department
of
insurance
has
given
rule
making
Authority
on
the
top
of
page
eight
and
then
there's
a
split,
effective
date
and
I
would
stand
for
any
questions.
B
Questions
for
Miss
Johnson
on
the
mechanics
of
the
bill:
okay,
Committee,
just
ratification
resident
Claus
tonight
did
have
a
working
group
with
a
lot
of
the
members
in
this
room
on
various
sides
of
the
bill
to
try
to
get
to
an
agreement,
or
at
least
the
working
draft.
Six
you
see
before
us
today
and
so
we'd
certainly
be
happy
to
answer
any
questions
or
we'll
interject
I.
B
Think
as
we
go
along
on
some
of
the
the
major
points
were
brought
up
during
that
three-hour
working
group
meeting
on
the
bill
with
that
I
don't
know
who
wants
to
jump
forward
and
go
first.
There
are
some
amendments,
maybe
Pharmacy,
and
then
maybe
we
can
do
insurance
next,
Miss
rinking
we'll
do
the
order
of
operations
of
kind
of
state
agencies,
and
then
we
can
get
into
greater
public
comments.
So
with
that
welcome
floor
is
yours.
AB
AB
You
there's
some
concerns
that
the
board
has
with
how
it's
currently
constructed
the
bill,
as
it
is
constructed,
ends
up
mandating
that
white
bagging
b,
a
service
that
b
provided
as
outlined
in
the
bill
that
presents
problems
for
delivering
patient
care
and
access
to
care,
because
it
pretty
much
removes
all
other
ways
where
these
medications
were
previously
being
administered
in
hospital
settings
or
clinics,
or
places
like
that.
The
bill
is
also
a
little
concerning
because
it
doesn't
distinguish
between
an
inpatient
and
an
outpatient
setting
when
these
drugs
can
be
administered.
AB
The
other
piece
that
is
a
little
concerning
to
the
board
is
the
new
section
2655-104,
which
end
up
putting
practice
requirements
for
pharmacies
that
would
be
participating
in
in
this.
That
would
meet
the
criteria
being
a
specialty
pharmacy,
but
those
practice
requirements
are
located
outside
of
the
practice
act.
So
we're
concerned
that
there
would
be
a
lot
of
confusion
and
misunderstanding
of
what
the
requirements
would
be
there.
AB
AB
This
new
supply
chain,
We
Believe,
would
end
up
increasing
costs
for
the
patients,
as
well
as
the
different
facilities
in
Wyoming,
as
well
as
ending
up
causing
situations
where
facilities
in
Wyoming
that
were
previously
providing
these
things
would
be
in
a
situation
to
where
they
would
not
have
stock
on
hand
to
be
able
to
use
in
the
event
that
medications
arrived
damaged
or
incomplete,
or
anything
like
that,
The
increased
cost
aspect
would
come
because
these
specialty
drugs
don't
always
come
as
a
final
dosage
form
that
could
be
administered
to
the
patient
a
lot
of
times.
AB
They
are
going
to
be
different
components
that
need
to
be
compounded
together
into
what
the
becomes
the
final
dosage
form.
So
the
facilities
would
still
need
to
maintain
very
expensive,
sterile
compounding
equipment
and
environment
environments
to
be
able
to
do
those
final
steps
and
make
sure
that
the
the
final
product
is
able
to
be
administered
to
the
patient.
AB
But
like
I
say,
the
the
bill
ends
up
creating
a
situation
where
hospitals
won't
have
stock
to
cover
mishaps
along
the
way
that
creates
a
situation
to
where
excess
stock
is
unclear.
What
happens
when
the
dose
isn't
right
and
whose
medication
that
ultimately
ends
up
becoming
there's
also
concern
about
the
requirements
on
page
six
and
subsection
b
line
seven
through
about
10,
which
requires
the
entities
involved
to
be
compliant
with
the
federal
drug
supply
chain
and
Security
Act.
AB
AB
We
do
have
some
of
our
hospitals
that
are
Jayco
or
Joint
Commission
accredited
and
that's
a
very
costly
accreditation
to
obtain
pharmacies
that
would
end
up
seeking
to
obtain
this,
especially
Pharmacy
accreditation
would
be
looking
at
something
like
a
3
500
application
fee
to
even
be
considered
to
be
a
specialty
pharmacy
plus
anywhere
from
fifteen
hundred
to
two
thousand
dollars
in
costs
for
hiring
consultants
and,
ultimately,
a
minimum
of
forty
to
fifty
thousand
dollars
in
maintaining
that
accreditation
for
a
period
of
of
years
and
that
can
vary
depending
on
who
ends
up
providing
the
accreditation
to
the
pharmacy.
AB
So
the
the
accreditation
piece
is
is
very
costly
to
require
different
pharmacies
to
do
or
to
require
our
hospitals
to
have
to
obtain
an
additional
accreditation
that
they
don't
have.
Currently
with
that
I'd
be
happy
to
answer
any
questions
that
you
may
have
about
the
bill,
or
about
about
that
we
do
have.
We
did
talk
with
Chairman's
wanitzer
about
some
recommended
changes.
B
B
Miss
Roday
and
we
do
have
a
couple
people
in
the
waiting
room,
we'll
bring
in
and
call
on
next,
but
with
that
Heather
welcome.
G
Good
morning,
Mr,
chairman
again,
my
name
is
Heather
Roday
and
I'm
from
Blue
Cross
Blue
Shield
of
Wyoming
wanted
to
visit
a
little
bit
about
this
bill
today
and
reiterate
that
we
want
our
members
to
receive
safe
and
effective
care
with
the
highest
quality
and
timeliness,
and
if
there
are
cases
where
their
safety,
it
requires
infusions
in
a
hospital.
We
support
that
and
we
pay
for
it.
G
However,
if
the
committee's
desire
is
to
move
ahead
with
some
legislation,
we
have
provided
some
suggestion
suggested
language
in
the
past.
Our
language
also
included
agreements
that
insurers
would
pay
hospitals
if
there
was
a
white
bagged
treatment
that
what
I'll
say
was
a
fail,
but
with
pricing
restrictions
that
could
prevent
markups.
G
G
Therefore,
we
have
concerns
about
the
current
language
and,
and
we
actually
interpret
the
language
a
little
bit
different
than
what
we've
heard
before.
It
appears
to
us
that
the
front
of
the
bill,
it
actually
bans
white
bagging
and
the
ability
to
seek
cost-effective
venues
for
our
members
and
then
at
the
back
of
the
bill.
It
offers
the
guardrails
that
were
suggested.
G
I
think
that
in
either
case
there
is
a
conflict
there
that
could
be
addressed.
You
have
a
lot
of
amendments.
I
know
that
to
the
existing
language
that
were
proposed
to
provide
some
clarity
being
very
clear
to
allow
white
bagging
with
guardrails
and
not
prohibit
alternate
sites
of
care.
These
amendments,
while
lengthy,
were
not
meant
to
kill
the
bill,
nor
are
they
meant
to
have
tricks
in
them.
G
We
actually
don't
understand
why
this
legislation
is
needed,
because
there
are
facilities
who
can
actually
prohibit
white
banging
on
their
own,
and
we've
also
heard
that
there
are
some
facilities
that
would
actually
like
to
be
able
to
do
it
so
that
they
won't
have
to
carry
inventory,
but
so,
given
the
complexity
of
the
bill
and
the
need
for
more
work
to
make
it
ready
for
prime
time,
we
respectfully
urge
caution
with
moving
ahead
ahead
with
this
bill.
G
As
it's
written,
we
really
have
had
conversations
and
we
have
tried
to
work
through
this
bill
with
other
stakeholders.
We
just
don't
think
we're
there,
yet
the
those
amendments
will
be
discussed
later,
and
we
hope
that
this
makes
it
clear
and
thank
you
for
the
opportunity
to
come
on
comment
on
this
today
standard
for
any
questions.
Questions.
B
For
Blue
Cross
the
scene
right
now,
Heather.
Thank
you.
Let's
go
online
Mr
ghee!
If
you
can
hear
us
the
floor,
is
yours.
AC
B
AC
Mr
chairman
members
of
the
committee,
I'm
Dr,
Alan
gee.
Thank
you
for
this
opportunity
to
offer
thoughts
regarding
this
proposed
legislation.
I
appreciate
the
concerns
for
the
delivery
of
Quality
Health
Care
in
our
state
and
as
a
practicing
neurologist
in
Wyoming
for
the
past
23
years.
I
do
have
patients
that
are
impacted
by
the
availability
and
delivery
of
biological
infusions
for
their
neurologic
disease.
AC
Given
the
challenges
we
face
with
the
availability
of
care
and
the
delivery
of
services,
I
have,
in
this
past
year
undertaken
efforts
to
create
more
opportunities
to
deliver
high
high
quality
biology
confusions
to
the
citizens
of
our
state
by
opening
outpatient
infusion
centers
in
multiple
communities.
I
have
taken
this
undertaken
a
significant
effort
in
expense.
AC
AC
My
concern
is
this:
legislation
will
impede
the
delivery
of
value-based
care,
though
the
intent
seems
to
be
to
improve
the
accessibility
and
availability
of
certain
medications.
It
seems
as
I
read
the
legislation
and
as
it's
written,
it
will
increase
the
cost
of
infusions,
decrease
the
access
to
infusions
and
decrease
the
quality
of
care
for
patients.
Some
examples
in
regards
to
the
cost.
Most
part
B
medications
have
coinsurance,
which
is
a
percentage
of
the
negotiated
rates
between
the
provider
and
the
payer.
AC
Health
Systems
have
higher
rates
and
therefore
patient
experiences
at
higher
cost
to
access
these
infusions
to
those
facilities.
In
regards
to
the
access
Wyoming
citizens
already
have
mechanisms
for
access
to
Hospital
infusion
centers
payers
have
the
ability
to
Grant
care
exceptions
based
on
Mobility
location,
accessibility
of
infusion
centers.
AC
AC
So
my
suggestions
that
this
legislation
proceeds
would
be
to
make
sure
we
have
modifications
to
enhance
business.
Competition,
enhance
transparency
and
consumers,
enhance
the
infusion
availability
and
access
and,
most
importantly,
enhance
quality
of
care,
rather
than
create
legislative
impediments
to
this
access
for
care
for
our
citizens.
Thank
you,
Mr
chairman,
and
also.
B
Thank
you,
Dr
gee,
so
I
just
want
to
make
sure
I
understand
your
testimony.
You
operate
an
infusion
center
clinic
that
patients
can
utilize
your
clinic
or
the
hospital
depending
on
that
patient's
choice.
Right
now
is
that
a
fair
assessment.
AC
J
You
Mr
chairman,
thank
you,
Dr
gee,
for
being
with
us
Dr.
Can
you
describe
the
supply
chain
custody,
making
sure
that
those
medications
that
you're
giving
to
patients
are
handled
appropriately
and
safe
safely
before
you
deliver
them
to
your
patients?
J
AC
Ahead,
Mr,
chairman
representative
carlston,
so
I
am
partnered
with
a
national
Pharmacy
and
National
infusion
company
that
is
in
charge
of
and
manages
that
supply
chain
delivery.
We
use
a
specialty
pharmacy
that
supplies
the
product
we
track
and
secure
the
shipments
and
the
deliveries
through
the
the
parent
company
of
Talus,
infusions.
B
Did
not
follow
up
any
other
questions,
not
seeing
any
right
now,
Dr
Keith,
thank
you
for
being
with
us,
we'll
keep
taking
public
comment
and
see
where
we
end
up
here.
AD
AD
I
I
just
wanted
to
thank
the
committee
and
thank
the
working
group
members
for
all
the
work
that
we
have
put
into
this
I
know
that
pcma
and
the
insurers
and
our
members
have
done
no
less
than
I.
Think
three
or
four
different
versions
of
you
know
language
that
you
know
we've
suggested
and
we've
supplied
the
last
of
which
I
sent
to
the
chairs
and
various
committee
members
of
which
I
do
have
the
list
of
amendments
and
I
apologize
that
there
are
I,
think
there's
like
49
or
54
of
them.
AD
My
numbering
got
off
at
the
very
end,
but
I
went
line.
We
went
line
by
line
and
I,
just
like
witness.
Roday
had
indicated
it's
not
our
entire
intent
to
kill
this
bill.
This
is
an
emerging
issue.
It
has
passed
in
Six,
States,
total.
So
far.
The
first
time
that
it
passed
was
in
Louisiana,
which
was
this
is
what
this
was.
AD
A
model
was
based
off,
of
which
I
believe
was
in
2020,
so
we
are
just
getting
in
to
see
you
know
what
the
effects
are
of
this
we're
happy
like
I,
said
to
work
with
everybody,
but
we
just
feel
that
this
is
as
you've
heard
previously.
This
is
a
very
contentious
and
it's
a
very
complicated
issue,
and
that's
why
we
have
so
many
amendments,
because
we
just
want
to
get
it
right,
so
we
I
can
talk.
AD
I,
don't
know
if
you
want
me
to
go
through
one
want
us
to
go
through
all
of
the
Amendments
I.
Don't
think
you
want
me
to
waste
that
time,
but
I
mean
I.
Think
just
a
lot
of
them
are,
you
know
just
correcting
some
things
and
then
just
you
know
putting
some
things
into
place
that
have
been
discussed
previously.
B
Any
kind
of
the
major
policy
I
mean
I
know
some
are
kind
of
technical
Corrections
and
some
morning
changes,
but
any
high
level
kind
of
policy
issues
you
have
with
the
the
current
legislation
would
be
great.
AD
I
I
would
say,
first
and
foremost,
is
the
you
know
relative
to
the
covered
benefits,
the
preservation
of
the
insurer
tools
for
use
of
in-network
providers
and
pharmacies,
which
I've
talked
about,
which
is
essentially
freedom
of
of
choice,
and
we
are
saying
that
that
eliminates
the
provider
networks
and
the
any
willing
provider
statute
in
Wyoming-
and
the
other
item
is
also
where
it-
you
know-
prohibits
white,
bagging
or
bans
it
and
then
also
allows
it
so
I
mean
those
are.
AD
That
is
the
the
two
issues
that
I
would
bring
to
your
attention.
B
AE
Good
morning
my
name
is
Lucina
Mendez
Harper
I'm,
a
pharmacist
and
I
work
with
Prime
Therapeutics.
We
are
a
pharmacy
benefit
manager
owned
by
not-for-profit
Blue
Cross
Blue
show
plans
Across.
The
Nation
certainly
appreciate
all
the
effort
that's
been
put
into
this
legislation.
AE
AE
Again
we
were
the
10
from
our
perspective
was
to
try
and
make
the
bill,
as
you
know
better,
as
as
most
we
could,
but
I
do
want
to
address
a
couple
of
things
and
I
that
were
said.
This
bill
doesn't
mandate
white
bagging.
What
the
intent
is
is
to
allow
it
as
an
option,
but
then
also
to
have
guard
rails
around
that
practice
that
so
that,
if
it
occurs,
there
are
guardrails
specific
to
the
safety
issues
that
were
raised
so
and
that's
that's
what
we've?
AE
What
we've
put
in
the
in
the
bill?
The
other
thing
I
want
to
just
clarify
and
make
sure
that
everyone
understands
is
white
bagging
is
provi,
is
the
drug
sourcing.
So
it's
actually,
how
are
you
getting
the
drug,
the
actual
drug
product,
it's
not
putting
it
together
and
getting
it
ready
for
Infusion
and
then
administering
it
it?
It's
not
that
process
at
all.
AE
It's
actually
what
Dr
gee
just
talked
about
how
he
uses
a
specialty
pharmacy
to
send
him
the
actual
drug
product
he
receives
that
and
then
he
does
all
of
the
admin
you
know
putting
it
together
into
an
infusion
dosage
form
and
then
administering
that
that
medication,
so
I,
just
want
to
make
sure
that
we're
there's
a
clear
understanding.
This
is
about
the
drug
sourcing,
it's
not
about
compounding
it
and
administering
it.
AE
That
would
still
occur
by
from
the
at
the
clinical
practice
site,
whether
it
be
a
hospital
or
a
infusion,
center
or
private
practice.
Setting,
let's
see
and
then
oh
one
other
thing
this
bill
doesn't
I,
don't
see
anywhere
in
here
where
it
prohibits
hospitals
from
having
medication
on
hand.
AE
J
Thank
you,
Mr
chairman.
Thank
you
for
being
here.
You
know
the
the
goal
of
this
was
really
the
patient
safety
and
we
all
had
concerns
that
we
shared
we
didn't
want
price
gouging
by
anyone
right,
but
we
want
to
make
sure
that
these
patients,
where
all
of
our
customers
are
taken
care
of
so
I,
appreciate
your
work
on
this
and
and
the
goal
of
this
was
never
to
completely
ban
white
begging
right
just
to
make
it
safer
for
Wyoming,
where
in
the
bill,
do
you
see
that
it
bans
white
begging.
B
AE
Sharon
swanitzer
and
representative
Clausen.
Thank
you
for
the
question.
It
wasn't
my
statement,
but
I
will
I
will
respond
to
it.
Page
five
says
that
a
health
insurer
shall
not
refuse
to
authorize,
approve
or
pay
a
provider,
a
participating
provider
for
providing
covered
provider,
administered
drugs
and
related
services
to
covered
persons.
AE
So
we
interpreted
that
as
a
white
bagging
band
then
later
on
in
the
bill
it
talks
about,
you
can
have
white
bagging
and
there
are
some
provisions
on
some
of
the
provisions
were
in
there
about.
You
know
if
there's
a
shipment
malfunction
and
a
way
to
access
it
locally
if
needed,
and
so
that's
really
where
we
were.
That
was
one
of
the
conflicting
elements
that
we
saw.
AE
There
was
also
some
conflicting
language
about
whether
you
could
have
differential
cost
sharing
based
on
where
that
side
of
care
was
was
performed
and
one
part
of
the
bill.
It
said
you
could
and
then
another
part
of
Bill.
It
said
you
couldn't
so
again,
our
our
amendments
were
were
trying
to
identify
and
fix
the
conflict.
What
we
interpreted
as
conflicting
Provisions,
but
also
reflecting
what
the
discussions
had
been
and
what
we
understood
to
be
a
general
agreement
on
what
the
intent
was,
that
we
were
trying
to
to
have.
B
B
F
I
I
I
We
did
have
a
significant
back
and
forth
discussions
on
this
bill
providers
and
I
greatly
appreciate
their
input
and
we're
all
trying
hard
to
come
up
with
Solutions
we're
just
not
quite
there
yet
I'm
going
to
talk
about
one
particular
amendment
that
I
was
involved
in,
because
I
was
trying
to
solve
a
problem
that
was
raised
during
the
working
group
and
then
we
worked
on
it
afterwards
and
that
is
frankly,
representative
closton's
experience
where
they
had
to
go
to
an
infusion
center
and
the
drug
wasn't
there,
and
so
there's
that,
and
sometimes
when
somebody's
at
a
hospital
or
an
infusion
center
or
the
provider
for
very
good
reasons,
says
well.
I
I
need
to
change
the
dosage
on
this
specialty
drug
infusion
and
in
those
two
circumstances
we
all
agreed
that
it's
completely
appropriate
for
the
hospital.
It's
going
to
be
a
Hospital
Pharmacy
generally,
let's
be
honest:
Specialty
Pharmacy,
it's
completely
appropriate
for
them
to
dispense
that
drug
versus
having
the
drug
delivered
from
the
National
Specialty
Pharmacy,
and
so
we
put
in
a
provision
that
that
allowed
for
that
we're
discussing
it.
It's
in
one
of
the
Amendments
that
you
see
the
concern
from
the
insurance
company
side
is
well.
I
That's
one
person
for
the
year
so
multiply
that
out.
These
are
Big
Numbers
we're
talking
about.
So
that's
why
they're
concerned.
So
the
concern
was
all
right:
we'd
like
to
have
the
medical
provider
be
able
to
provide
that
drug
in
those
circumstances,
so
the
patient
isn't
inconvenience
or
put
at
risk
the
dosage
change,
but
what
kind
of
Cost
Containment
can
we
agree
on?
And
that's
where
we
haven't
come
to
agreement?
Yet
right
we
aren't
what
our
proposal
was
well,
that
you
meet.
I
You
meet
the
costs
that
our
Specialty
Pharmacy
is
charging
us
right
and
they've
said
well.
We
have
concerns
about
that
and
truthfully
one
of
the
questions
was
well.
Would
a
Hospital
Pharmacy
potentially
lose
money
and
the
truthful
answer
is
it's
possible
and
we
haven't
come
up
with
a
solution
for
that
and
we'd
all
like
to
we
just
we're
still
working
on
it
and
no
one's
acting
in
bad
faith.
I
We
just
haven't
gotten
to
a
solution
to
that
particular
question
yet,
but
you
do
see
at
least
the
amendment
on
allowing
the
hospital
to
prepare
the
drug
and
get
it
to
the
patient,
and
it
does
have
our
provision
and
it
says
you
meet
the
Specialty
Pharmacy
rate.
Okay,
so
I'm
gonna
go
I,
wanted
to
just
discuss
that
particular
Amendment
with
you,
so
you
understood
the
background
and
that
we
want
to
solve
that.
I
That
problem
I
think
the
that
you
heard
the
pharmacy
board
expressed
concern
about
the
provisions
on
page
nine
and
thereafter,
which
is
that
if
a
health
insurer
is
going
to
be
require
the
specialty
pharmacy
to
deliver
that
drug
to
the
infusion
center
directly
that
that
Specialty
Pharmacy
has
to
comply
with
certain
things,
I
think
in
all
good
faith
that
those
don't
aren't
really
regulatory
restrictions
on
pharmacies.
I
It's
a
regulatory
restriction
on
an
insurer
to
make
sure
the
pharmacy
can
do
this
stuff
and
we're
told
that
our
National
Specialty
pharmacies
can
do
this
stuff
and
the
local
Community
Pharmacy.
Do
it
probably
not,
but
I'm,
not
sure
the
local
Community
Pharmacy
wants
to
stock
those
incredibly
expensive
specialty
drugs
either
I
could
be
wrong,
but
that's
I
mean,
like
I,
said
it's
a
500
000
per
drug.
I
That's
a
lot
of
money
to
be
carrying
for
stock
right.
So
the
point
there
is.
We
need
some
more
engagement
right.
We
need
some
more
engagement
with
Pharmacy
boards,
so
they're
comfortable
or
we're
comfortable,
and
we
don't
want
to
pass
a
bill
that
causes
problems
within
Pharmacy
regulation
when
really
what
we're
trying
to
regulate
is
insurer
practice
right,
so
I
think
there's
more
engagement
needed
there.
There's
more
engagement
needed
overall
from
a
public
policy
standpoint:
okay,
I
I
want
to
just
give
you
a
few
numbers.
Mountain
Health
Co-Op
has
60
000
members.
I
I
You
already
know
your
insurance
rates
are
high.
There's
just
another
example
of
it.
Bills
that
stray
outside
of
the
norm
are
different
or
costly.
Simply
raise
that,
because
we
we
pass
that
on
to
the
rate
payer
right
and
from
a
public
policy
perspective.
That's,
unfortunately,
the
the
charge
that
you
are
all
charged
with.
You
can
say
that
there's
a
significant
need
in
white
baking
and
Direct
Delivery
of
specialty
medicines,
and
that
we
want
to
restrict
the
ability
of
insurance
companies
to
incentivize
use
of
lower
cost
infusion.
I
Centers,
okay,
which
is
going
to
raise
rates,
or
you
can
say
we're
more
concerned
about
keeping
rates
stable,
and
we
don't
want
to
do
this
or
we'll
change
some
things
in
the
bill
to
make
it.
So
it's
not
quite
as
as
bad,
and
it
doesn't
restrict
the
competition
that
insurance
companies
want
to
see
because
we
want
to
be
able
to
incentivize
and
educate
our
members
about
safe
and
effective
alternatives
to
sites
of
care.
So
I
understand,
that's
a
tough
public
policy
position.
I
get
it
right!
That's
why
you
get
paid
the
big
bucks
right.
I
We
all
know
you're,
making
big
bucks,
but
there
it
is
I
mean
that
from
our
standpoint
there
it
is,
am
I.
Leaving
is
my
company
leaving
the
state
if
the
bill
passes
absolutely
not
we're
committed
to
Wyoming
and
we're
staying,
but
costs
get
passed
through.
Thank
you,
Mr,
chairman,
happy
to
answer
questions.
Thank.
J
Thank
you
Mr
chairman,
thank
you.
Mr
Spencer,
page
six,
you've
kind
of
sort
of
referred
to
this
lines
9
through
12.,
so
it
talks
about
health
insurance
issues,
agreement
with
the
participating
provider
and
if
no
rate
is
established
in
the
agreement
at
the
wholesale
acquisition
cost,
who
determines
the
wholesale
acquisition
cost?
If
Mountain
Health
in
one
of
our
hospitals
cannot
come
to
an
agreement
on
a
price.
I
Mr,
chairman
representative,
well,
the
wholesale
acquisition
cost
is
kind
of
a
term
of
Art
in
the
community,
but
I
think
you
raise
an
excellent
question.
Right.
Is
wholesale
acquisition
cost
the
invoice
from
the
wholesaler
to
the
pharmacy?
Does
that
give
you
a
true
picture
of
their
their
acquisition
cost
I'm
gonna?
It's
an
easy
number
to
get
right.
I
In
addition
to
all
of
those
things
on
the
back
end,
they
also
get
a
substantially
reduced
price
from
the
manufacturer
for
those
drugs,
none
of
which
are
shown
on
that
invoice
from
the
wholesaler
to
the
provider
to
the
pharmacy.
So
it's
there
and
yes,
that's
the
invoice
but
I
don't
believe
it's
an
accurate
reflection
of
the
true
cost
and
it
is
a
complicated
cost
to
figure
it
out.
It's
very
complicated.
J
Thank
you,
Mr
chairman,
you
know
the
other
cost
would
be
shipping
costs
cost
to
a
facility
as
far
as
getting
it
from
where
it's
shipping
to
the
pharmacy
compounding
the
medicine,
so
there's
other
costs
in
there.
So
again,
one
of
my
concerns
is
you
know:
I
want
the
patient
to
get
the
medicine
when
needed,
and
you
know
I
don't
want
to
see
a
250
000
medicine
being
charged
half
a
million
dollars
for
so
I
guess.
This
is
one
of
my
sticky
points
that
I'd
like
to
see
some
resolution
on.
I
I
Okay,
those
are
all
part
of
the
package,
but
you
raise
an
excellent
point
and
that
is
you
know
there
that
medicine
has
to
be
compounded
and
then
administered
and
absolutely
providers
deserve
to
be
paid
for
that
and
we
should
be
negotiating
appropriate
rates
with
them
to
do
that
and
have
no
problems
doing
so
we're
paying
for
it
today.
But
if
it's
not
the
appropriate
rate,
it
certainly
can
be
negotiated.
B
X
Chairman
committee
members,
Melinda
Carroll
with
the
Wyoming
Pharmacy
Association
I'm,
also
a
practicing
pharmacist
and
I
am
very
familiar
with
several
issues
that
have
been
brought
up
so
on
the
cost.
The
wholesale
acquisition
cost
I
would
like
to
address,
saying
that
we,
you
know
showing
the
invoice
doesn't
show
our
actual
cost.
I
can
tell
you
on
brand
name
medications
and
Specialty
medications.
Rebates
don't
happen.
What
Mr
Spencer
was
referring
to.
Usually
when
you
get
rebates
through
your
wholesale
drug
supplier,
it
is
because
of
bulk
purchases,
and
that
is
bulk
purchases
on
generic
medications.
X
So,
let's
be
very
clear
on
the
cost
of
the
medication.
I
am
not
going
to
speak
to
the
hospital
side
of
that.
The
340b
is
absolutely
something
that
reduces
cost,
and
if
they
are
a
340b
entity,
they
should
be
charging
340b
prices,
I'm
sure
that
Josh
can
speak
to
that
a
little
bit
better
than
I
can
to
clarify
that
cost
piece
in
there.
The
other
thing
that
I
would
like
to
address
is
saying
that
this
bill
bans
white
bagging.
X
With
that
statement
on
five,
it
is
not
Banning
white
bagging,
it
is
making,
so
it
is
not
mandated,
because
many
of
these
health
plans
are
mandating
that
white
bagging
occurs,
and
so
that
is
taking
away
patient
Choice.
It
is
taking
away
patient
access
to
care.
It
is
further
narrowing
networks
and
that's
what
we're
concerned
about
are
those
things,
and
so
I
would
argue
that
this
does
not
ban
the
practice.
It
says
that
they
shall
not
mandate
it
in
their
contracts.
X
Also,
I
would
like
to
address
saying
that
our
community
pharmacies
are
not
able
to
provide
these
Services
I
wholeheartedly
believe
that
our
community
pharmacies
can
provide
these
services,
and
there
are
several
in
Wyoming
that
do
follow
sterile,
compounding
they
are
inspected
by
the
our
Board
of
Pharmacy
and
inspected
two
standards
of
USP
797
USP
800,
and
there
are
pharmacies
in
this
state
that
have
additional
certifications
to
compound
specialty
medications
and
do
contract
with
health
provider
or
health
insurance
providers
to
deliver
those
medications
to
people's
homes
for
home
infusion
and
can
provide
them
to
infusion
centers.
X
So
having
further
regulations
on
pharmacies
in
this
bill
absolutely
regulates
Wyoming
pharmacies
because
Wyoming
pharmacies
are
providing
these
services,
and
so
this
is
an
inappropriate
place
to
have
that
section
on
regulating
Pharmacy.
That
would
go
in
the
pharmacy
Practice
Act
and
we
are
opposed
to
having
that
in
here
at
all,
and
so
that
would
be
the
entirety
of
section
I
believe
it
is
26
54
155
the
whole
last
section,
Pages
9
10.
Basically
all
of
11.,
so
I
would
ask
that
the
committee
take
that
and
strike
that.
X
Yes,
absolutely
we,
the
pharmacy
Association,
also
would
like
to
bring
up
the
concerns
that
were
stated
by
the
Board
of
Pharmacy
with
having
the
language
in
it
requiring
the
compliance
with
the
drug
supplies
chain.
Security,
Act
dscsa.
X
The
FDA
has
already
pushed
this
go
live
date
back
a
full
year
to
November
of
24
and
based
on
industry
comment.
It
could
be
a
moving
date
that
we're
looking
at
so
having
this
language
in
the
bill
could
potentially
allow
health
insurance
plans
to
not
comply
with
subsection.
A
of
that
particular
section,
let
me
find
you
that
it's
page
five
subsection
a
that
basically
is
saying
that
they
shall
not
mandate
this.
X
They
could
call
it
call
into
question
the
the
drug
viability
and
say
that
it
is
it's
not
viable
and
therefore
they
don't
have
to
comply
with
this
and
they
can
use
their
own
Specialty
Pharmacy
to
do
it,
and
so
it
would
be
a
loophole
and
I
would
highly
recommend
taking
that
language
out
to
prevent
that
loophole
from
being
their
with.
That.
X
I
would
also
recommend
that
we
that
you
reject
the
proposed
language
for
medical
necessity
that
is
Page
seven
line
17
through
27
those
recommended
revisions
to
medical
necessity.
So
medical
necessity
should
never
include
location
of
service,
and
that
is
what
they're
trying
to
include
in
that.
If
the
medication
is
medically
necessary,
it
will
remain
that
way
whether
the
patient
receives
the
medication
at
an
infusion
center
or
at
a
hospital
I
would
advise
the
committee
to
not
accept
that
alternative
language
in
the
staff
comment.
X
If
there
needs
to
be
further
clarification
on
that,
I
have
heard
some
statements
on.
You
know
that
language
not
being
entirely
clear.
There
are
alternate
sources
of
that
language.
There
is
model
legislation
that
the
Americans
Society
of
Health,
System,
permissive
or
Pharmacy
has
that
is
been
used
in
a
couple
different
states
as
well.
X
So
as
I
discussed
page
nine
I
would
strike
page
nine
page
10
page
11
lines,
one
and
two
so
mandating
strict
qualifications
to
dispense.
Specialty
medications,
while
well-intentioned,
can
have
unintensive
unintended
consequences
and
hinder
patient
access
to
essential
treatments.
The
qualification
requirements
will
limit
the
number
of
pharmacies
and
Healthcare
professionals
who
can
dispense
specialty
medications.
This
limitation
in
turn
reduces
the
availability
to
these
crucial
treatments
for
patients,
particularly
in
underserved
and
rural
areas.
X
X
Statutes
and
regulations
are
meant
to
ensure
fair
and
consistent
standards
that
protect
the
public
interest,
allowing
those
to
be
regulated
being
drafted
by
those
that
it
is
regulating.
In
this
instance,
Health
insurers
can
sometimes
be
a
conflict
of
interest,
and,
in
this
particular
instance,
I
believe
it
is
I
believe
that
these
particular
restrictions
would
encourage
use
of
specialty
mail
order,
pharmacies
that
are
often
times
owned
by
the
health
insurers
themselves,
keeping
that
Profit
Stream
in
their
wheelhouse.
X
This
is
also
being
investigated.
As
we
all
know
federally.
The
FTC
is
investigating.
There
are
several
bills,
federally
that
are
going
through
right
now.
That
is,
that
is
looking
at
this
very
particular
issue,
as
well
as
other
issues
in
regards
to
these
industry
practices.
U
Thank
you,
Mr
chairman
members
of
the
committee,
Josh
hanis
with
the
Wyoming
Hospital
Association,
so
if
I
could
go
back
and
and
provide
just
a
little
context
for
the
committee,
so
we
came
during
the
interim
and
asked
for
this
topic
to
be
considered,
and
then
we
brought
model
legislation
out
of
Louisiana
which
to
oversimplify
would
eliminate
the
practice
of
white
bagging
and,
and
this
committee
assigned
a
working
group
to
look
at
that
and
Mr
chairman.
U
You
were
part
of
that
representative
closton
representatives
from
the
various
insurance
companies
participated
in
in-person
meetings
back
and
forth
emails
phone
calls
and
I
and
I
would
like
to
say
that
I
do
appreciate
the
willingness
to
work
on
these
issues
with
the
people.
Who've
testified
previously
on
this
I
do
think
it
has
been
Cooperative.
I.
U
Think
people
have
come
to
the
table
in
good
faith
to
talk
about
this
and,
as
you
noticed,
obviously
from
the
dozens
of
amendments
from
insurance,
some
of
which
I
frankly
agree
with
we've-
maybe
confused
the
issue
a
little
bit
and
caused
some
unnecessary
complication
and
I
have
to
own
some
of
that
right
when
I
participate
in
things
I'm
known
to
screw
it
up.
U
So,
let's
see
if
we
can't
get
back
on
track
a
little
bit,
but
what
I
would
like
to
do
is
talk
a
little
bit
about
our
concerns
and
then
maybe
offer
a
way
to
simplify
what
we're
trying
to
accomplish.
So
our
concerns,
as
you've
heard
from
from
others,
have
to
do
with
when
you
win
a
hospital
anyway,
I'll
only
speak
for
hospitals
when
they
procure
drugs,
specialty
or
otherwise
they
come
through
a
a
normal
process.
U
We
have
insight
into
that
supply
chain
from
the
when
it
leaves
the
manufacturer's
facility
to
when
it
arrives
in
ours.
We
have
a
number
of
regulations
on
how
we
manage
that
inventory.
How
we
entered
into
our
electronic
health
records
it's
often
barcode
scanned.
Some
of
those
processes
are
automated
for
efficiency's
sake.
When
they
come
in
a
in
a
different
way,
it's
a
white
bag,
drug
that
comes
outside
of
our
normal
procurement
process.
We
don't
have
insight
into
that
supply
chain
and
where
it
comes
from
they're,
often
not
barcode
scannable.
U
So
it
requires
manual
entry
into
our
electronic
health
record.
They
also
have
to
be
managed
separately
from
the
rest
of
our
inventory,
because
they're
patient
specific,
as
you've
heard
I,
think
representative
closton
brought
this
up
and
and
perhaps
Bruce
as
well,
is
that
it
could
come
in
a
dosage
that
was
appropriate
at
one
visit.
But
when
the
patient
comes
back
to
have
it
administered,
another
dosage
would
be
appropriate
for
whatever
reason,
and
then
there
can
be
delays
in
care.
U
We
also
wouldn't
have
necessarily
a
lot
of
confidence
in
if
it
needs
to
be
temperature
controlled,
so
in
transport
wasn't
managed,
was
it
handled
and
maintained
in
a
way
that
by
the
time
it
gets
to
us
and
is
ready
to
go
to
the
patient
that
it's
safe
to
use?
And
so
what
you
heard
at
your
last
committee
meeting
from
our
pharmacist
was
that
a
lot
of
that
medication
gets
spoiled
and
wasted
and
sits
around
you
can't
use
it.
U
So
those
are
so
those
are
our
concerns
on
sort
of
the
administrative
side
and
the
patient
safety
side
we
do
have
as
it
relates
to
what
we'll
call
Patient
steering
is.
We
we
believe
in
patients
should
have
options
to
go
to
an
appropriate
setting
of
care,
and
when
we
had
our
our
working
group
meeting
I
think
there
was
some
lack
of
understanding
about
you
know
these
other
places
may
be
lower
cost,
but
what
is
their
level
of
safety?
And
how
is
that
monitored?
U
I'm,
not
casting
dispersions
on
any
other
provider,
I'm,
not
saying
they're
unsafe,
but
some
insight
into
how
that's
managed
and
monitored
and
understanding
so
that
we
can
make
public
policy
decisions
about
where
appropriate
settings
of
care
actually
are.
But
I
do
want
you
to
hear
I'm
not
saying
insurance
companies
are
sending
people
to
unsafe
providers,
I'm
not
saying
that,
but
it
would
be
they're
not
regulated
the
same
way.
A
hospital
is,
for
instance,.
U
So
so,
let's
maybe
talk
about
how
we
could
simplify
and
I-
haven't
talked
about
this
with
the
working
group,
but
maybe
offer
for
your
consideration.
I,
don't
think
it's
necessarily
a
meet
in
the
middle.
Oh!
No
excuse
me
one.
Second,
let
me
back
up
the
rate
when
we're
talking
about
rates
for
payment.
Those
are
negotiated
rates.
U
Insurance
companies
may
think
they're
too
high
that
they're
inflated
I
mean
this
is
like.
We've
talked
about,
there's
some
inherent
tensions
between
payers
and
providers,
but
those
rates
are
negotiated.
U
They're
not
they're,
not
surprises,
but
that
being
said
is
there
a
way
that
we
could,
like
I,
said,
simplify
this
process,
where
we
say
in
statute
that
an
insurance
company
can
and
Montana
has
attempted
some
of
this
language
recently
that
an
insurance
company
can
say
can
offer
or
request
that
the
specialty
drug
be
provided
in
this
white
bagging
process,
a
facility
could
say
yes
and
then
you
proceed
and
move
forward
and
the
patient
gets
served,
but
if
they
say
no,
if
the
facility
doesn't
want
to
take
on
that
risk,
could
we
make
it
so
that
the
hospital
in
our
case
serves
the
patient?
U
They
submit
a
bill
that
gets
paid
because,
right
now,
if
they
deny
or
do
not
accept
white
bagging
drugs,
they
could
deny
the
claim,
and
so
there's
some
decisions
to
be
made
by
the
facility
in
those
cases.
So
I
realized
that
this
is
just
coming
now.
It
probably
requires
some
conversation,
but
I
offered
that
to
you
as
another
way
to
consider
working
on
this
issue
and
with
that
at
Stanford
questions,
questions.
J
U
Mr,
chairman
representative
closton,
so
we've
spoke
to
our
members
about
this
issue
specifically
and
in
in
the
spirit
of
compromise
we
would,
we
would
be
okay
in,
in
these
cases,
talking
about
a
way
to
say
cap
what
the
what
the
charge
would
be
in
a
hospital
setting
the
concern
there
becomes.
First
of
all,
what
is
it
right?
You
heard
Mr
Spencer
talk
about
their
suggestions,
which
we
can't
accept,
but
but
where
is
where
is
The
Sweet
Spot?
U
U
Is
the
legislature
interested
in
rate
setting
and
and
getting
involved
in
making
statute
that
says
what
something
should
cost
or
what
you
should
pay
for.
It
so
I
hope
that
answers
your
question.
B
B
Q
Welcome
thank
you
Mr
chairman,
for
that
introduction,
an
interesting
one.
My
name
is
Ralph
Hayes
I
am
the
manager
of
the
employees
and
officials
Group
insurance
program,
at
least
up
until
December
29th
of
this
year
and
yes,
I
have
announced
my
retirement
and
after
22
years
in
this
position
in
this
particular
piece
of
legislation
on
the
white
bagging,
I,
I
guess
from
my
perspective,
it
does
impact
our
program.
Q
So
there
is
a
fiscal
impact,
because
I
do
believe
that
this
prevents
steerage
away
from
providers
and,
while
I
appreciate
the
hospital's
position
that
those
particular
drugs
are
negotiated
as
far
as
their
total
package
of
reimbursement.
Q
Q
So
negotiation
can
be
tricky
and
you,
quite
frankly,
the
insurers
don't
have
a
lot
of
Leverage
in
that
particular
area
and
part
of
the
leverage
they
do
for
those
negotiation
is
moving
care
where
appropriate,
to
these
infusion
situations
to
an
alternate
side
of
care.
If
that
goes
away,
which
in
way
I
read
this
bill,
it's
a
it's
unfair
trade.
Q
If
you
move
that
care
somewhere
else
and
the
insurer
is
painalized,
then
it
stays
with
the
hospital
at
quite
frankly,
in
a
lot
of
cases,
an
exorbitant
rate
and
Blue
Cross
gave
you
an
example
and
I've
seen
examples
myself,
for
example,
some
medications
for
ananasia
after
dealing
with
some
Cancer
Treatments,
which
is
administered
the
next
day
in
a
markup
on
that
is,
like
eighteen
thousand
dollars
over
cost.
So
we
that's
the
kind
of
money
we
save
every
time.
Those
get
moved
to
a
different
facility
in
there.
B
AF
Sorry
there
we
go
unmuted
good
afternoon,
Mr,
chairman
and
members
of
the
committee.
I'll
keep
this
kind
of
short
I.
Don't
have
a
lot
to
add
to
the
discussion.
I
would
just
like
to
to
reiterate
the
comments
that
my
associate
Melinda
Carroll
made
and
also
the
hospital
Association.
AF
You
know.
Really
this
bill
is
is
I.
Guess
from
from
our
antenna.
Looking
at
it
was
was
not
preventing
the
practices
of
white
bagging,
but
just
preventing
the
mandating
of
it
to
reiterate
reimbursement
rates
are
negotiated,
they
are
set
forth
by
insurers
and
organizations
and
and
moving
forward.
We
are
a
a
Community
Pharmacy
that
does
Supply
some
of
those
specialty
medications
for
our
local
addiction
treatments,
buy
and
belt
program.
AF
The
comments
that
are
made
that
that,
if,
if
you
know,
white
begging
is
continued
to
be
allowed
and
and
insurance
is
mandated,
that
that
hospitals
or
other
providers
could
could
turn
around
and
rebuild
those
medications
from
from
stock,
if,
if
white
begging
medications,
don't
arrive
in
time,
it's
it's
quite
simple:
we're
not
going
to
stock
those
medications
if,
if
we're
not
able
to
routinely
sell
them
the
the
comments
regarding
whack
and
the
acquisition
costs
on
those
specialty
items
and
all
the
discounts
that
that
are
behind
those.
AF
AF
It
is
what
it
is.
I
mean
it's
it's
what
we
are
paying
on
those
invoices,
those
those
rebates
that
that
are
supposedly
flowing
into
pharmacies
and
and
I
I
can't
comment
on
hospitals,
because
that's
that's
not
what
I'm
familiar
with,
but
but
those
those
dollars
just
just
aren't
there,
and-
and
this
is
really
a
workaround-
we
have
medical
contracts
and
reimbursement
contracts
with
maximum
allowable
costs
set
between
us
and
the
insurer
and
and
those
are
negotiated
and
and
agreed
upon
prior
to
Services
being
provided.
AF
Nothing
in
in
the
bill
originally
stated
that
that
that
there
couldn't
be
differences
between
in-network
and
out
of
network,
so
I
I
don't
see
the
concerns
that
are
that
are
being
raised
there.
But
if,
if
one
infusion
center
or
or
one
side
is
in
network,
you
know
the
patient
shouldn't
be
penalized
from
choosing
one
in-network
provider
over
over
being
steered
to
a
facility.
That's
that's
owned
by
by
the
insurer.
That's
that's
100
miles
away
that
that
they've
got
to
drive
there
and
and
eat
that
cost,
and
this
is
this.
AF
Bill
is
really
trying
to
maintain
I
guess
originally
patient
access
and
and
and
providers
access
to
being
able
to
provide
care,
and
with
that
I
guess
I
would
I
would
stand
for
questions
from.
N
B
Any
other
public
comment
all
right,
we'll
close
public
comment:
hey
so
committee.
Let's
have
a
quick
talk
about
how
this
works
and
I
know.
Representative
Klaus.
Tonight
we
sat
on
a
working
group.
We
thought
we
got
to
a
gritty,
a
pretty
good
place,
the
legislation
we
went
back
and
looked
at
our
laws
and
what
a
specialty
pharmacy
is
and
how
we
do
specialty
drugs,
there's
just
still
a
lot
of
inconsistencies
as
I
think
you
heard
and
I
at
least
would
say.
B
From
my
perspective,
everybody
on
this
issue
really
has
tried
in
good
faith,
to
get
to
where
we're
going
and
be
agreeable.
So
I'm
I
think
we
can
have
about
an
hour
of
amendments
and
discuss
some
of
them,
maybe
get
it
to
session
I
think
we
could
have
another
meeting
in
November
either
a
zoom
meeting,
an
in-person
meeting
for
one
day
on
this
and
I
was
kind
of
thinking
on
prior
off,
but
that
went
a
little
differently
than
I
thought.
It
would
all
right.
B
You
know
we
can
put
it
on
the
agenda
for
next
year
and
so
I
guess
what
I'm
asking
is
we're
probably
going
to
break
the
lunch?
Have
some
internal
communication
kind
of
figure
out
where
we
are
see
what
you
want
to
do
decide
if
you
want
to
have
another
meeting
to
discuss
this
I
think
we
would
have
another
meeting
among
all
the
interested
parties
in
a
working
group
before
another
legislative
meeting.
So
we
could
come
to
you
with
some
pretty
strong
agreements,
maybe
one
or
two
policy
questions
and
Hammer
it
out.
B
I
think
is
where
I
would
like
to
go,
but
if
you
want
to
discuss
it
over
lunch
with
each
other,
maybe
with
some
of
the
people
who've
been
involved,
see
where
they
want
to
go.
That's
probably
my
ask
with
that.
Is
there
anybody
and
I'm
still
kind
of
in
the
middle
of
this?
So
I
can't
move
on
to
the
next
topic.
But
let
me
check:
is
there
anybody
who
can't
wait
for
another
hour
and
15
minutes
to
testify
for
the
from
EMS?
B
B
or
120
whenever
we
get
a
quorum
and
then
we'll
figure
out
a
way
forward
here
on
the
white
bagging
bill,
talk
to
the
governor's
office,
I,
don't
believe
they
need
an
hour
and
she
did
email,
I.
Think
us
last
night.
B
Did
you
email,
the
entire
committee
Jen
just
me
we'll
send
it
out
to
to
all
of
you
on
kind
of
what
the
ask
is
going
to
be
on
the
governor's
EMS
task
force
and
where
we're
hoping
to
go
there
and
think
we
can
knock
that
out
in
15
minutes
and
still
stay
on
agenda
for
the
rest
of
the
day.
So
anybody
have
any
comments
before
we
break
for
lunch
great
for
break
for
lunch.
I'll
see
you
back
here.
Let's
say:
1
20.
enjoy
beautiful
Saratoga.