North Carolina Considers ‘Overhauling’ Prior Authorization For Health Insurance

Health InsuranceFebruary 6, 2025

Health insurance in North Carolina is under the microscope as lawmakers consider significant changes to prior authorization requirements. These rules, often criticized for delaying care and increasing administrative headaches, may soon be overhauled – or even banned entirely.

Two Republican legislators, Rep. Timothy Reeder and Rep. Donny Lambeth, are leading the charge. Reeder, an emergency physician, and Lambeth, a former hospital executive, believe the system has become too burdensome for patients and doctors.

While no specific bill has been filed yet, the pair confirmed that prior authorization reform will be a top priority as lawmakers return to Raleigh.

What Is Prior Authorization & Why Does It Matter?

Prior authorization is a process where your doctor has to get approval from your health insurance company before you can receive certain treatments, tests, or medications. Insurers say it helps control costs by avoiding unnecessary or less effective care.

But for many patients and doctors, it is a headache that delays care and adds unnecessary stress.

Reeder points out that the process often requires significant time and effort from both physicians and patients. “It is burdensome,” he says. “It can delay care, and that is a problem.”

The Archives / In 2023, Reeder sponsored a bill to reform prior authorization, which passed the House but stalled in the Senate.

That bill proposed setting time limits for insurance reviews and ensuring that decisions are made by licensed, experienced doctors in North Carolina.

There is A Call for a Complete Ban

Lambeth has taken a firmer stance, advocating for the outright elimination of prior authorization requirements. He shared a personal experience to illustrate the system’s flaws: After undergoing a routine test, he learned his insurer wouldn’t cover the cost.

Weeks of back-and-forth with an out-of-state review company followed before the claim was finally approved.

This kind of experience, Lambeth argued, is not unique. “Patients should trust that when their doctor orders a test, it is necessary and will be covered,” he said. Under his proposal, prior authorization would be eliminated entirely, allowing doctors – not insurers – to determine what care is appropriate.

What Does This Mean for Patients and Doctors?

At the heart of this debate is the question of who should decide what care is necessary: doctors or insurers? Opponents of prior authorization argue that the process puts profits ahead of patients, forcing them to endure unnecessary delays and administrative hurdles.

Shvets / Pexels / For doctors, it is a constant struggle to provide the best care while battling for approval from insurance companies.

Reeder and Lambeth’s efforts reflect growing frustration with a system many view as outdated and harmful. With health insurance policies touching nearly every North Carolinian, the outcome of this debate will have far-reaching implications.

There’s A Broader Push for Change

The conversation is gaining momentum beyond the legislature. The North Carolina Medical Society (NCMS) is rallying support for reform. The group announced a press conference featuring its president, Dr. John Meier IV, and Amanda Watson, a metastatic breast cancer patient who has faced her own struggles with prior authorization.

Watson’s story shows how these policies can affect patients dealing with life-threatening conditions. Delays in treatment approvals can have devastating consequences, making reform an urgent matter for advocates like the NCMS.

The press conference will also include remarks from House Speaker Destin Hall and lawmakers like Reeder, Lambeth, and Rep. Larry Potts, who co-sponsored the 2023 reform bill. Their collective voices may help shape the future of health insurance in the state.