News from the South - Alabama News Feed

States try to rein in health insurers’ claim denials, with mixed results

Published

1 month ago

March 25, 2025

Staff Editor

alabamareflector.com – Shalina Chatlani – 2025-03-25 18:01:00

by Shalina Chatlani, Alabama Reflector
March 25, 2025

This story originally appeared on Stateline.

Health insurance companies are under increasing scrutiny for allegedly using artificial intelligence bots and algorithms to swiftly deny patients routine or lifesaving care — without a human actually reviewing their claims.

The high-profile killing late last year of UnitedHealthcare CEO Brian Thompson has focused even more attention on so-called prior authorization, the process by which patients and doctors must ask health insurers to approve medical procedures or drugs before proceeding. There had been protests and outrage over the company’s practices for months before Thompson’s death, and UnitedHealthcare has been accused in a class-action lawsuit of using AI to wrongfully deny claims.

As more patients and doctors voice their frustrations, states are responding with legislation designed to regulate prior authorization and claims reviews. So far this year, lawmakers in more than a dozen states are considering measures that would, for example, limit the use of AI in reviewing claims; exclude certain prescription medications from prior authorization rules; ensure that emergency mental health care is not delayed for more than 48 hours; and require that insurers’ review boards include licensed physicians, dentists or pharmacists with clinical experience.

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Insurers have long required doctors to obtain their approval before they’ll pay for certain drugs, treatments and procedures. They argue it is necessary to rein in health care costs and limit unnecessary services. But many doctors and patients say the practice has gotten out of hand, causing delays and denials of care that are harming and even killing people.

In a survey last year by the American Medical Association, 93% of doctors said that insurers’ prior authorization practices delayed “necessary care” for their patients. Twenty-nine percent said such delays had led to a “serious adverse event,” such as hospitalization, permanent injury or death.

In 2023, insurers selling plans on the marketplaces created under the Affordable Care Act denied a combined average of 20% of all claims. Of the 73 million in-network claims they denied, only 1% were appealed, according to KFF, a health policy research group.

The federal role

Under the Biden administration, the Federal Trade Commission and the Department of Justice took a firmer hand against health care corporations alleged to be engaging in behavior resulting in limited and more expensive care for patients. The administration also approved rules requiring that beginning in 2026, Medicare and Medicaid plans create a streamlined electronic process for reviewing claims, making decisions more quickly and providing specific reasons for denying care.

But it’s difficult to hold insurers accountable, according to Timothy McBride, a health policy analyst and co-director of a program at the Institute for Public Health at Washington University in St. Louis.

“Each part of the health care industry — hospitals, pharmaceuticals, insurers — they all have a lot of concentrated power,” McBride said in a phone interview. “And unless somebody actually takes it on directly, it’s going to stay that way. I think the Biden administration tried to take it on, but didn’t make a lot of progress.”

It’s unclear whether the Trump administration and Congress will reverse course. During his confirmation hearing on March 14, Dr. Mehmet Oz, President Donald Trump’s pick to lead the Centers for Medicare & Medicaid Services, defended the use of artificial intelligence in reviewing claims.

“AI can be used for good or for evil, and it to a large extent depends on who’s using it and for what purpose,” Oz told members of the U.S. Senate Finance Committee. “I think AI could play a vital role in accelerating preauthorization.”

In the past, Trump has supported measures to help patients, such as increasing hospital price transparency and lowering prescription drug prices, McBride noted. But “Republicans and conservatives generally are anti-regulation,” he said. “My gut feeling would be that they back off on the Biden push on this.”

States have limited power to act on their own. They have authority only over state-regulated health plans, which include Medicaid, plans for state workers and policies residents purchase from the ACA marketplaces. About 90 million people are covered that way. State laws do not apply to the 156 million workers, retirees and dependents who get their coverage through employer-sponsored health plans, which are regulated through a federal law known as ERISA.

Furthermore, health insurance companies are large and have deep pockets, allowing them to easily absorb state fines.

But Kaye Pestaina, the director of the program on patient and consumer protection at KFF, said states have an important role to play.

“Much of the focus around prior authorization at the federal level has kind of originated from state protections, so I imagine there will be continual activity by state legislatures to come at the problem,” Pestaina told Stateline.

What states are doing

Pestaina said states are trying a number of solutions. For example, states such as Arizona, Michigan and Pennsylvania have given their insurance regulators more authority to directly access claims denial information, in order to overturn decisions or potentially enforce state rules. And these efforts have largely had bipartisan support.

There is a role for some oversight to make sure that things are covered. But right now, I think the system is out of balance.

– North Carolina Republican state Rep. Timothy Reeder

In Pennsylvania, Republican state Sen. Kristin Phillips-Hill pushed through bipartisan legislation in 2022 to streamline prior authorization practices for state-regulated health plans after hearing numerous complaints from patients and doctors.

The legislation created an Independent External Review organization that allows Pennsylvanians to submit an online form to request a review if their insurer denies a service or treatment. If the review organization decides the service should be covered, the insurer must do so. Before then, patients could turn only to a federal review process, which may have been more challenging to navigate and taken more time.

“Our reforms created clear rules, clear timelines for the prior authorization process, and it removed ambiguity or uncertainty from the system that at times, insurers could exploit and providers could be confused over,” Phillips-Hill told Stateline. “Prior to that reform, if you had a denial from your insurer, you had very little recourse.”

The program began in January 2024, and in its first year the Pennsylvania Insurance Department overturned half of 517 denials, which amounted to claims from 259 people.

Jonathan Greer, president and CEO of the Insurance Federation of Pennsylvania, said his trade group worked with lawmakers to come to an agreement on how to change the prior authorization process in a way that worked for insurers and patient advocates. Greer says he thinks Pennsylvania could be a model for other states.

“Prior authorization, I think unfairly, has been characterized as a reason to say ‘no’ by insurers,” Greer said. “The purpose of prior authorization is to make sure that you know the care that you get is consistent with the care that you need.”

In North Carolina, Republican state Rep. Timothy Reeder is hopeful that his prior authorization bill will make it across the finish line this year. Reeder’s bill would set tight deadlines on insurers’ claim decisions and require companies to have licensed practitioners on their claim review boards. Insurers would also have to publicize a list of services they require authorization for.

“I’m not saying that we need to get rid of it completely,” Reeder told Stateline. “There is a role for some oversight to make sure that things are covered. But right now, I think the system is out of balance.”

But some state laws have proven to be less effective than advertised.

In 2021, Texas enacted a first-of-its-kind law creating a “gold card” standard, under which physicians whose care recommendations are approved by insurers at least 90% of the time are exempt from the prior authorization process. But as of the end of 2023, only 3% of Texas physicians had earned gold card status, according to the Texas Medical Association.

That’s why the group is pushing legislation that would require insurers to report which preauthorization exemptions they granted and denied and how many claims went to independent review. Dr. Zeke Silva of the Texas Medical Association’s legislative council said it would be “in the same spirit” as what Pennsylvania has done.

“Our focus with the [Texas Medical Association] is our physicians being able to provide the best care possible. And we want that to be free of burden,” Silva told Stateline. “We want to minimize third parties coming in and inappropriately denying care that our physicians and our patients think is in their best interest.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org.

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Alabama Reflector is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Alabama Reflector maintains editorial independence. Contact Editor Brian Lyman for questions: info@alabamareflector.com.

The post States try to rein in health insurers’ claim denials, with mixed results appeared first on alabamareflector.com

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News from the South - Alabama News Feed

Alabama Legislature sends 2026 ETF, General Fund budgets to Gov. Kay Ivey

Published

15 hours ago

April 30, 2025

Staff Editor

alabamareflector.com – Alander Rocha – 2025-04-30 07:01:00

by Alander Rocha, Alabama Reflector
April 30, 2025

The Alabama Legislature Tuesday gave final approval to the state’s two budgets for the 2026 fiscal year, but not without a battle.

The Alabama Senate passed a $3.7 billion 2026 General Fund budget late Tuesday night on a 30-0 vote after an hours-long slowdown.

HB 186, sponsored by Rep. Rex Reynolds, R-Huntsville, would provide a 10% increase ($347 million) over the current budget for the 2026 fiscal year, which starts October 1.

“In many cases, you had a reduction in what your request had been. Everyone of us had that … so we’re in a dichotomy here where we have the largest budget we’ve ever had, and yet, we have the tightest constraints and control that we’ve had in recent memory,” said Sen. Greg Albritton, R-Atmore, who chairs the Senate Finance and Taxation General Fund Committee, pointing to Medicaid’s significant budget increase that will bring its budget to over $1 billion.

Sen. Rodger Smitherman, D-Birmingham, asked for the 125-page funding bill to be read in its entirety Tuesday afternoon, which delayed the vote by hours. He said after the Senate adjourned that he didn’t want controversial bills to be passed without deliberation, and that he was afraid the Senate would move to adopt a different set of bills to consider.

“[The House] did have a second calendar, and it was going to be the same thing here in terms of the desire to have a second calendar, and I thought that we need to just work on that particular calendar,” Smitherman said after the Senate adjourned.

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The Alabama Medicaid Agency, which provides health insurance for over 1 million Alabamians, nearly all children, elderly citizens and those with disabilities, will get $1.179 billion from the state, a $223.8 million (19%) increase over this year. Ivey requested $1.184 billion in February, about $5 million more than what the House approved.

The Alabama Department of Corrections, which administers the state prisons, will get a $90.1 million increase (11%) to $826.7 million.

The Alabama Department of Human Resources, which provides child and adult protective services, enforces child support payments and administers food and family assistance, will get $148.9 million from the state in 2026, a $4.7 million (3%) increase from the current budget.

The Alabama Department of Mental Health, which provides mental health care services in the state, will get a $4.7 million increase (2%) to $244 million. The Legislature cut the funding from Ivey’s recommendation by $3.7 million.

But senators also appeared to want to send a message to the Alabama Board of Pardons and Paroles, which has drawn mounting criticism from Democratic and Republican senators over low parole rates and what senators consider a lack of responsiveness to their questions about the parole process. The Senate cut the board’s funding from $94.5 million to $90.6 million, a 4.1% decrease.

In addition, Sen. Clyde Chambliss, R-Prattville, added an amendment to make funding for the Board of Pardons & Paroles conditional on the board developing parole release guidelines. The amendment passed on a 27-0 vote.

“What they do, as y’all know, they adopt guidelines. Those are supposed to be updated and revised. They have not done that,” he said.

The board has faced backlash after parole rates declined significantly after 2017, when members granted parole to about 54% of applicants. The rates fell as low as 7% at times, according to an analysis by the ACLU of Alabama in 2023, but rebounded to slightly more than 20% within the past year.

The Senate also passed HB 185, also sponsored by Reynolds, which would appropriate $50 million in American Rescue Plan Act (ARPA) funds to the Department of Finance and provide over $12.6 million to the Unified Judicial System.

“This bill is supplemental monies just taking federal money and appropriating it,” Albritton said.

The House concurred with the changes late Tuesday evening, sending the bill to Gov. Kay Ivey.

The Senate also concurred with House changes to SB 112, sponsored by Sen. Arthur Orr, R-Decatur, a nearly $10 billion 2026 Education Trust Fund budget (ETF).

The House changes added $17.6 million to the budget, bringing it to a 6% increase over the 2025 ETF budget. The budget does not contain pay raises for teachers in the 2025-26 fiscal year, which starts Oct. 1. But it includes a $99.2 million increase for the Public Education Employees’ Health Insurance Plan, as well as funding for workman’s compensation for education employees and paid parental leave.

The Senate also concurred with the ETF supplemental funding bills, including SB 113, also sponsored by Orr, a $524 million 2025 supplemental appropriation for education that passed the House with an amendment changing language to clarify dual enrollment programs funding.

The Senate also concurred with House changes to SB 111, sponsored by Orr, which would appropriate $375 million over three years to implement changes to the state’s school funding formula.

The House added an additional $80 million from the Education Opportunity Reserve Fund to the Creating Hope and Opportunity for Our Students’ Education (CHOOSE) Act Fund, a voucher-like program that gives tax credits for non-public school spending, including private school tuition. The first-year cost estimate will go from $100 million to $180 million, an 80% increase. Over two-thirds of applicants to the program are already in private school or are homeschooled.

The story was updated at 10:30 a.m. to include comment from Sen. Rodger Smitherman, D-Birmingham, regarding the procedural delay.

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The post Alabama Legislature sends 2026 ETF, General Fund budgets to Gov. Kay Ivey appeared first on alabamareflector.com

Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Centrist

The content primarily reports on the legislative proceedings and budget approval in Alabama, focusing on the specifics of the Senate’s actions, including discussions and amendments. The tone is factual, without clear support or opposition to any political party or position. It details the actions of both Republican and Democratic senators, presenting them neutrally. The mention of funding allocations, including increases for Medicaid and the Department of Corrections, appears to be a straightforward report on the outcome of legislative decisions, without showing favor to any side. The coverage adheres to neutral, factual reporting rather than offering an ideological stance.

News from the South - Alabama News Feed

Bail reform bills moving through Alabama Legislature in final days of session

Published

1 day ago

April 29, 2025

Staff Editor

alabamareflector.com – Ralph Chapoco – 2025-04-29 07:01:00

by Ralph Chapoco, Alabama Reflector
April 29, 2025

Two bills that would change Alabama’s bail system are working their way through the Legislature in the waning days of the 2025 session.

The Senate Judiciary Committee hosted a public hearing Wednesday for HB 42, sponsored by Rep. Chris England, D-Tuscaloosa, which gives judges the authority to allow defendants to pay a portion of their total bond to be released from pretrial detention.

HB 410, sponsored by Rep. Shane Stringer, R-Citronelle, which was approved by the House Judiciary Committee, modifies the composition of the Alabama Professional Bail Bonding Board, expands the exemptions for the fees that bail bond companies must pay the court, increases penalties for bail jumping and adds more regulations for bail bond companies when they operate in another state.

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A message was sent to Stringer Monday seeking comment.

HB 42 has passed the House and is awaiting a vote in the Senate Judiciary Committee. The House is scheduled to vote on HB 410 on Tuesday. England’s bill adds three words, “a part of” back into an Alabama statute that were removed when the same Legislature enacted the Alabama Bail Reform Act of 1993.

The removal of the words meant judges in the state could not allow defendants to pay a percentage of their bond to get release from pretrial detention.

“What that translates into is a large amount of money that would normally go to the court system, instead of going to the court system, it goes to a bondsman,” England said to the committee Wednesday.

People can secure their release after an arrest if they pay a bail bond company. The premium, which is typically 10% of the total amount of the bond, is paid to the bail bond company, which then must ensure the individuals go to their court appearances.

The money that people pay when released on a percentage bond would be retained by the court and kept if defendants fail to appear for their court dates.

The Alabama Bail Bond Association has been a vocal opponent of the bill, speaking out against the legislation at a March public hearing and the House Judiciary Committee considered it then and eventually approved the bill a week later.

Victor Howard, vice president of the Alabama Bail Bond Association and bail bond company owner, said that enacting the legislation would reduce accountability for defendants to appear for their court dates.

Chris McNeil, the president of the Alabama Bail Bond Association, suggested Monday in an interview that the rates that people would not appear for court would increase. He also cited records from the Alabama Administrative Office of Courts saying that people who paid cash to be released from pretrial detention in 2022 and 2023 had a failure to appear (FTA) rate of 55%.

“The court just can’t function when you have a failure to appear rate of 55%,” McNeil said Monday. “The bonding companies were averaging about a 14%-15% failure to appear rate. And were able to trim that rate by returning defendants back to court.”

England told the committee that the numbers do not present a fair comparison to percentage bonds.

“The numbers are obviously going to be off because there are more people on smaller offenses with cash bonds versus somebody who is on a large bond with a bondsman,” England said to the committee on Wednesday. “Obviously, there is going to be a higher number of FTAs on smaller cases, traffic tickets, because they all count.”

Jerome Dees, policy director from the Southern Poverty Law Center, supported the legislation.

“The vast majority of times when there was an FTA that was ultimately secured, and the defendant showed up in court, it largely was due to law enforcement bringing that individual in and not the bail bond company,” he said to the committee on Wednesday. “That is not to say that it never happened, but the vast majority of time it was law enforcement bringing that particular individual in.”

McNeil said in an interview Monday he supports HB 410, Stringer’s bill.

“It expands the Alabama Professional Bail Bonding Board by adding a sheriff to the board, adding a layperson, so I think that is very important,” he said.

It also states that any fees that bail bond companies pay to the court that have not been deposited within 90 days and that have an expiration date “shall be deemed uncollected” and will no longer hold the bail bond company responsible for making the payment.

The bill also exempts bail bond companies from fees that the courts or district attorneys have not attempted to collect past one year from the original due date.

HB 410 also adds more conditions such that the bail bond company will not pay a fee, known as forfeiture, to the court when in cases that the defendant fails to appear in court.

McNeil said the bill would cancel that forfeiture payment if someone was not placed in the National Crime Information Center and failed to appear in court, or if the bail bond company brings back a defendant that the jail refuses to accept.

The bill also addresses instances when an individual travels out of state and enhances the penalty for bail jumping, going from a Class A misdemeanor to a Class D felony, punishable by up to 5 years in prison and a $7,500 fine.

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The post Bail reform bills moving through Alabama Legislature in final days of session appeared first on alabamareflector.com

Political Bias Rating: Center-Left

The content focuses on legislative efforts to reform Alabama’s bail system, highlighting a bill sponsored by a Democratic representative aimed at allowing partial bond payments to reduce the financial burden on defendants. It presents arguments from both supporters and opponents, including the bail bond industry’s concerns and civil rights advocacy perspectives. The article leans slightly left by emphasizing criminal justice reform and the perspective of proponents seeking to reduce penal system inequities, yet it maintains a generally balanced tone by including conservative viewpoints and the legislative process details.

News from the South - Alabama News Feed

7-Year-Old Calls 911, Helps Save Family Member's Life | April 28, 2025 | News 19 at 10 p.m.

Published

2 days ago

April 28, 2025

Staff Editor

www.youtube.com – WHNT News 19 – 2025-04-28 23:17:38

SUMMARY: Seven-year-old Maddux Kendrick from New Market showed remarkable bravery by calling 911 when his stepmom, Megan Douglas, who has epilepsy, suffered a seizure on New Year’s Day. While playing video games and watching TV, Maddux noticed Megan fell and was having a seizure. Calmly, he first called Megan’s mother and then 911, providing precise information and helping the operator monitor Megan’s breathing until EMTs arrived. His quick thinking likely saved her life, as she later had another seizure and might have suffered worse alone. Maddux received a Good Samaritan Award for his courage and presence of mind, making his family very proud.