The Maryland Insurance Administration (MIA) has posted the recording and presentation materials from the Workgroup to Study the Rise in Adverse Decisions in the State Health Care System – Meeting Four, held on June 11.

This meeting occurred the day after Commissioner Marie Grant participated in the APTA Maryland Payment Symposium on June 10. The webinar provides additional context on the Commissioner’s perspectives regarding adverse decisions, prior authorization, and care access.

For those interested in these topics, I recommend viewing the discussion from 45:30 to 1:26:00, which focuses primarily on prior authorization and adverse decision trends.

Key Discussion Highlights

• Adverse Decision Trends: Commissioner Grant reviewed both state and national grievance data, noting that approximately 10% of adverse decisions under MIA oversight are appealed, with roughly 50% of those decisions being overturned. She raised important questions regarding the reasons for this high overturn rate and the impact that delayed services may have on patient care.
• Prior Authorization and Formularies: Commissioner Grant also discussed how evolving formulary requirements and prior authorization processes may be contributing to the increase in adverse decisions and creating additional barriers to timely care.

The presentation from the Maryland Managed Care Organization (MCO) Association also provides valuable insight into the distinction between medical necessity adverse decisions and claims denials, emphasizing that these are separate issues being evaluated by the Workgroup. The discussion includes how prior authorization processes and administrative delays may influence patient access to care.

Another noteworthy segment begins at approximately 1:57:00, where Dr. James York discusses emergency department utilization among patients with musculoskeletal (MSK) conditions. The panel explored strategies to improve MSK care, including:

• Expanding access to physical therapy services within emergency departments.
• Reducing reliance on prescription-based management when appropriate.
• Revisiting prior authorization requirements for physical therapy referrals.

The discussion also referenced payer initiatives in several states that have eliminated or relaxed prior authorization requirements for an initial course of physical therapy (e.g., the first 10 visits).

These conversations align with Commissioner Grant’s broader interest in examining how prior authorization requirements and adverse decisions may contribute to delays in care, including transitions from acute care hospitals to post-acute settings.

Members interested in payment policy, utilization management, and access to musculoskeletal care are encouraged to review the webinar and accompanying presentation materials.