MedChi, The Maryland State Medical Society

Ocotber 16, 2026

Sent via [email protected]
The Honorable Marie Grant Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202

RE: Comments on Workgroup to Study the Rise in Adverse Decisions Recommendations and Discussion

Dear Commissioner Grant: 

On behalf of our client MedChi, The Maryland State Medical Society, and the patients served by MedChi's member physicians, MedChi appreciates the opportunity to submit comments regarding recommendations discussed during the October 8th meeting of the Workgroup on the Rise of Adverse Decisions. Below are comments and additional points from MedChi for the Workgroup to consider. 

Recommendation 1: Require public posting for clinical criteria for private review agents that are Commercial Insurers, P BMs, and Managed Care Organizations (MC Os). This requirement would not apply to Medicaid Fee-for-Service but its clinical criteria for commonly requested medications are currently posted. The MIA should conduct periodic sample audits of clinical criteria used for prior authorizations for compliance. Maryland Medical Assistance Program will continue to provide oversight for the MCO prior authorizations process and is currently working to implement routine clinical appropriateness audits of pre-service managed care denials and use findings to remove overly restrictive clinical criteria. Maryland Medical Assistance Program requires MCOs to ensure clinical criteria and medical necessity determinations are not overly restrictive compared to that of Fee-for-Service. 

MedChi supports this requirement. During the 2024 Legislative Session, SB791/HB923: Health Insurance - Utilization Review - Reforms required that commercial carriers "post on its website or the carrier's website the specific criteria and standards to be used in conducting utilization review of proposed or delivered services and any subsequent revisions, modifications, or additions." Unfortunately, this requirement was subsequently changed to only "require posting to the member's or provider's pages of the carrier's website." This change reduced transparency and made compliance harder to ensure. In addition, MedChi strongly supports applying the same criteria and standards to managed care organizations, especially since many are now owned by commercial carriers. Lastly, MedChi supports the MIA conducting periodic sample audits of clinical criteria and believes that, for this requirement to be effective, it must also be supported with stronger enforcement penalties when criteria are not followed. Along this same line, any audit conducted should also include the requirement contained in § 15-1 0B-07 of the Insurance Article, which requires that the physician making the adverse decision or who is required to participate in the mandatory peer-to-peer must be board-certified or eligible in the same specialty as the treatment under review and knowledgeable about the requested health care service or treatment tlu·ough actual clinical experience. This is equally important to ensure that the criteria are being applied correctly. 

Recommendation 2: Require Application Programming Interface (AP!) requirements under the Centers for Medicare and .Medicaid Services (CMS) interoperability and prior authorization rule in Maryland Commercial market on or before July 1, 2028. 

MedChi supports this requirement. However, we would like to better understand how this requirement complements existing requirements in Maryland law, such as the requirement in § 19- 108 .5 of the Health-General Article [1] and the requirement in§ 15-10B-06 of the Insurance Article related to timeframes for making a prior authorization decision.

Recommendation 3: MIA should update and simplify the complaints process for consumers and providers, working with the new Health Insurance Advisory Board. MIA will work on a uniform, plain language appeal.form and/or electronic process. The Maryland Medical Assistance Program will collaborate with the MIA to determine reasonable modifications to its appeal process that would remain in compliance with state and.federal regulations, improve plain language on forms, and allow closer alignment. MHCC, MIA, and the Maryland Medical Assistance Program should work together to identify payer outliers and reasons for variability in denial rates, and enforce where appropriate for the agency. 

MedChi supports this requirement. Again, Med Chi wants to emphasize that administrative requirements between commercial insurers and managed care organizations should be better aligned to simplify the process for providers. While Medicaid is always concerned about adding costs, greater alignment on complaint and appeals processes is an administrative effort and should not add to the State's overall Medicaid budget. Additionally, previous Workgroup discussions focused on whether to use a uniform form to file an appeal. We think this warrants further discussion. Given the administrative burdens that prior authorization and utilization review requirements place on providers, many providers now rely more heavily on patients to file appeals. The Explanation of Benefits form sent to patients only provides limited information on filing an internal appeal. For example, the language in CareFirst's EOB simply states "[y Jou, or your authorized representative, or your health care provider acting on your behalf, have the right to file an appeal. The appeal must be in writing and sent within 180 days of the date of this notice to the mail administrative address below ... Include any additional information that you would like us to consider regarding this claim. CareFirst will respond to you, and your authorized representative, and your health care provider acting on your behalf, within 60 working days." 

If the State does not want to mandate a form, it should require that additional information be included on the EOB to better assist patients in understanding what to include in an appeal request, which could avoid delaying the review and eliminate the "back and forth" that occurs when the patient does not know what to include. Similarly, MedChi wants to highlight a provision in thestatements EviCore Healthcare sends to patients, an entity CareFirst uses to determine medical necessity and appropriateness.

​Your request has met medical criteria review. The authorization number is not a guarantee of payment. This authorization is applicable as long as you are eligible, still participating, and have not exhausted any applicable benefit limits on the date you receive services.

While this statement may meet the letter of the law, it confuses the average consumer and may lead them to believe that, even with an "approved" test, the carrier will ultimately not pay for it. Information sent to consumers must be clear and avoid ambiguity. This statement does neither and can easily lead consumers to decide not to proceed with the "approved" health care services or to file unnecessary appeals. 

Other Issues 

At the last Workgroup meeting, the issue of "goldcarding" was discussed. Since 2018, the insurance industry has committed to streamlining and reducing prior authorization requirements, including implementing a "goldcard" standard. As of this date, it is our understanding that no Maryland insurer has implemented or tried to implement this standard. MedChi supports implementing this standard, but it must include safeguards to ensure it is implemented, not "in name only," and that the standards are achievable, streamlined, and reduce the prior authorization process for both patients and providers. 

In addition, MedChi would be remiss if we did not challenge the assertion that prior authorization, as imposed by commercial insurers, is necessary to protect consumers. This argument overlooks a fundamental inequity in the health care system where physicians and other health care practitioners are held to rigorous clinical, ethical, and professional standards and face potential medical malpractice liability for their clinical decisions, while commercial insurers routinely make consequential decisions about medical necessity and access to care without being held to equivalent standards or facing comparable accountability when their decisions result in harm. 

Insurers should not be allowed to substitute their administrative and :financial interests for the clinical judgment of treating practitioners, especially when those practitioners are best positioned to understand their patients' individual medical needs. Far from reliably protecting consumers, unnecessary prior authorization requirements, inappropriate denials, and administrative delays create barriers to medically necessary care, disrupt treatment, jeopardize patient outcomes, and impose significant administrative burdens on providers. Moreover, delaying or denying appropriate care does not eliminate costs. Instead, it often shifts and compounds them, leading to avoidable emergency department visits, preventable • hospitalizations, disease progression, and more costly interventions. A process purportedly designed to protect patients cannot be considered successful when it obstructs timely, medically necessary care, undermines treating practitioners' clinical judgment, and ultimately increases costs to the health care system. MedChi urges policymakers to prioritize patient access, provider autonomy, and clinical decision­making over insurer-driven administrative barriers and to hold commercial carriers meaningfully accountable for the consequences of their determinations. 

As always, MedChi thanks the MIA and the Workgroup to Study on the Rise of Adverse Decisions for allowing MedChi the opportunity to submit these comments. 

Sincerely,

Donna L. Kauffman, Esquire
On Behalf of MedChi

Schwartz, Metz, Wise & Kauffman, PA
20 West Street
Annapolis, MD 21401

[1]

Section 19-108.5 states "[o]n or before July 1, 2026, a carrier shall establish and maintain an online process that:

(i) Links directly to all e-prescribing systems and electronic health record systems that use the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard;

(ii) Can accept electronic prior authorization requests from a health care provider;

​I. For which no additional information is needed by the carrier to process the prior authorization request

2.     For which no clinical review is required; and

3.     That meet the carrier's criteria for approval; and