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PC 967

Para enmendar el Artículo 19.150 de la Ley Núm. 77 de 19 de junio de 1957, según enmendada, conocida como “Código de Seguros de Puerto Rico” a fin de que sea una práctica prohibida de las compañías aseguradoras que ofrecen planes de cuidado de salud desautorizar una orden médica provista a un suscriptor; enmendar el Artículo 35 de la Ley Núm. 139 de 1 de agosto de 2008, según enmendada, conocida como la Ley de la Junta de Licenciamiento y Disciplina Médica para definir como práctica ilegal de la medicina el que una persona que no sea médico pase juicio sobre una orden médica como parte de un proceso de autorización de cubierta de seguro y para otros fines.

2025-2028 Session

Puerto Rico bill prohibits health insurers from overriding physician orders and classifies non-doctor judgment of medical orders in insurance authorizations as illegal practice.

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Bill Summary · PC 967

Legislative bill overview

Bill PC 967 amends Puerto Rico's Insurance Code and Medical Licensing Law to prohibit health insurance companies from denying or overriding medical orders issued to subscribers. It also classifies as illegal medical practice any non-physician's judgment of medical orders during insurance coverage authorization processes.

Why is this important

This bill directly affects healthcare delivery by restricting insurance companies' ability to second-guess physicians' clinical decisions through prior authorization denials. For patients, this could mean faster access to prescribed treatments; for insurers, it significantly limits cost-control mechanisms commonly used in managed care; for physicians, it reinforces their clinical autonomy.

Potential points of contention

  • Insurance company operations: Severely restricts prior authorization denial authority, which insurers argue is essential for controlling fraud, unnecessary procedures, and healthcare costs
  • Definition scope: "Non-physician judgment" language is broad—unclear if it applies to nurse reviewers, medical directors with MDs, or algorithm-based systems, creating implementation ambiguity
  • Healthcare costs: Removing authorization denials could increase insurance premiums if physicians over-prescribe or prescribe unnecessarily expensive treatments without financial accountability
  • Patient access vs. fiscal responsibility: Balances patient rights against insurers' legitimate need to manage unsustainable medical spending and prevent unnecessary care

Compiled from official sources — confirm details with the bill’s official record.

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