Stories from Texas Medicine, September 2017

Heavy Resistance - 09/27/2017

Prior authorizations started as a way to control the cost of prescription drugs. But in recent years, they've ballooned into an industry within the medical industry ― one that touches almost everything doctors do for patients. Agreements between health plans and participating physicians now regularly include rules that allow insurers to require prior authorization on the medical need for surgery, imaging, and medication ― in fact, just about every kind of treatment or test.

A Peer? Nowhere Near - 09/05/2017

Health plans regulated by the Texas Department of Insurance (TDI) must give a practitioner a chance to explain to a physician why a treatment is medically necessary or appropriate before a utilization review agent denies the request. Texas laws and TDI regulations don't expressly state that a physician who handles a peer-to-peer call has to be of the same or a similar specialty.

A Fresh Set of Eyes - 09/05/2017

For prior authorizations, insurance companies often require peer-to-peer conversations between a patient's physician and another physician to determine whether the treatment is necessary. These conversations often result in Texas doctors explaining the necessity of the treatment to a physician who's not licensed in Texas and/or is in an unrelated specialty.

Steering Clear of Trouble - 09/01/2017

Pharmacies that compound topical creams and gels of questionable or nonexistent efficacy and then bill insurance for huge amounts are a growing problem, especially in the Texas workers' compensation program. Sometimes, they convince physicians to play a part in their schemes, offering kickbacks or other inducements in exchange for referrals. It's a nasty business doctors need to know is out there — and strictly avoid.