Comprehensive Prior Authorization Reforms Needed, Medicine Tells Feds - 11/30/2023

As the Centers for Medicare & Medicaid Services (CMS) seeks ways to relieve the burdens of prior authorization on health care, it should not rely solely on automation of electronic health records. Instead, CMS should seek comprehensive reforms that include transparent PA requirements and protections of continuity of care as well as automation, the Texas Medical Association, American Medical Association, and a host of other medical societies wrote in a letter to CMS Administrator Seema Verma last week.

Putting the AI in Paid: Payer Use of Artificial Intelligence Sparks Physician Concerns - 10/02/2023

Physicians - worried about payers' increasing use of artificial intelligence to process prior authorization requests, enable value-based care models, and systematically deny coverage - are seeking transparency on behalf of their patients and practices.

Humana Claims Issues Require Resubmission Due to Technical Error - 09/01/2023

Practices that used Mimecast's secure message portal to submit claims issues, questions, or appeals to Humana between July 17 and Aug. 28 will need to resubmit those reports due to a technical error.

TMA Wins Fourth Lawsuit Challenging Payment Calculations in Surprise Billing Arbitration - 08/28/2023

Marking a fourth victory for the Texas Medical Association in as many lawsuits, a court struck down a large portion of the regulations setting forth a methodology insurers use to calculate the qualifying payment amount, or QPA, used in surprise-billing disputes – part of a series of federal rules TMA has long argued skew the arbitration process in insurers’ favor.

TMA Welcomes New Court Ruling in NSA Lawsuit - 08/25/2023

Statement by Rick W. Snyder II, MD, Texas Medical Association (TMA) president, in response to the ruling by the U.S. District Court for the Eastern District of Texas regarding TMA’s third No Surprises Act (NSA) lawsuit.

TMA Resumes In-Person Meetings with Major Texas Payers - 08/25/2023

After a pandemic-induced hiatus, the Texas Medical Association recently resumed in-person meetings with Texas’ major payers to solve physicians’ payment policy problems, a practice that dates back more than 25 years.

CMS to Recoup Chronic Care Management Payments - 08/21/2023

Some Texas physicians and outpatient facilities might have to refund payments they received for chronic care management services performed during 2015 and 2016 under the Medicare Physician Fee Schedule, federal officials said.

Report: Most Private Payers Have Stopped COVID Cost-Sharing Waivers - 08/21/2023

Private health insurance plans have largely stopped waiving patient cost-sharing for COVID-19 treatment, according to a recent report by the Peterson Center on Healthcare and Kaiser Family Foundation. The data represent an overwhelming shift from payer cost-sharing policies during 2020 as indicated by previous research.

United Will Eliminate Prior Authorization Requirements for Certain Procedures - 08/11/2023

Physicians have long complained about onerous prior authorization requirements, which often delay care and sometimes have catastrophic consequences. One payer seems to be listening.

Court Delivers TMA Win Against Fee Hike, Batching in Surprise Billing Arbitration - 08/10/2023

The court struck down a 600% administrative fee increase and certain unfair rules that narrowed the law’s provisions on combining or “batching” surprise-billing arbitration claims. The decision is one of several victories TMA has won against federal regulators tasked with implementing the federal No Surprises Act.

TMA Pleased Court Strikes Down Steep Fee Hike and Batching Rules in NSA Cases - 08/08/2023

Statement by Rick W. Snyder II, MD, Texas Medical Association (TMA) president, in response to the ruling by the U.S. District Court for the Eastern District of Texas on TMA's fourth No Surprises Act lawsuit. TMA challenged a 600% hike in administrative fees and batching rules used in arbitration cases governed by the federal law.

TMA Opposes Congressional Proposal to Cap Office-Based Physician Pay - 08/07/2023

A recently filed federal bill would recycle a controversial formula that TMA has waged several lawsuits against in the federal surprise billing regulatory context to limit payments for health care services furnished in physician offices.

Patient Care Protected: Prior Authorization Reforms - 08/04/2023

Carrying the torch from last session, the Texas Medical Association followed up on its 2021 gold-card success with a new prior authorization reform for vulnerable patients and other insurance-related policy wins this session.

New TMA Lawsuit Challenges Big Fee Hike in “No Surprises Act” Arbitration - 08/04/2023

The Texas Medical Association (TMA) is challenging a 600% hike in administrative fees for seeking federal dispute resolution in No Surprises Act (NSA) situations. TMA seeks relief by filing a fourth lawsuit in the U.S. District Court for the Eastern District of Texas.

TMA Pleased by U.S. District Court Ruling Granting Summary Judgment Motion - 08/04/2023

Statement by Gary W. Floyd, MD, Texas Medical Association president, in response to the U.S. District Court for the Eastern District of Texas granting TMA’s motion for summary judgment in its lawsuit opposing certain components of federal regulatory agencies’ final rules regarding dispute resolution under the No Surprises Act.

Payers Axe Consultation Codes - 07/25/2023

Both Cigna and UnitedHealthcare (UHC) have announced that starting in October, they will no longer pay for CPT consultation codes 99241-99245 – office consultations – and 99251-99255 – inpatient consultations. UHC’s policy change becomes effective Oct. 1, as outlined in its March bulletin. Cigna’s July newsletter says Cigna’s policy takes effect Oct. 19.

Court Hearing Approaches in TMA Surprise Billing Lawsuit - 07/17/2023

With a Feb. 4 court hearing on the horizon, the Texas Medical Association recently reiterated its strong opposition to a part of a federal rule that medicine says unfairly favors health insurers when directing arbiters to resolve payment disputes between insurers and physicians under the federal surprise billing law.

Study: Health Plan Directories Remain Spotty Despite Legislative Intervention - 06/12/2023

Health plans continue to maintain inaccurate directories of in-network physicians and other health care professionals, despite a federal law that aims to ensure such directories are up to date.

TMA Moment in Time: Texas' First PPO Rules - 06/05/2023

TMA fought to ensure fair regulation of PPOs, which now dominate the health plan market.

TMA to Congress: Support Increased Competition, Transparency in Health Care - 05/04/2023

Statement by Texas Medical Association (TMA) President-Elect Rick Snyder, MD, in response to the U.S. House Energy and Commerce Committee’s Health Subcommittee hearing Wednesday on transparency and competition in health care.

“Gold Card” Cleanup, Network Adequacy Bills Head to House - 04/21/2023

Building on years of Texas Medical Association advocacy, two House committees cleared a pair of bills that would strengthen existing state laws and regulations by further easing health plans’ onerous prior authorization requirements and strengthening network adequacy protections.

Update: TMA Pushes for Compliance With Second Surprise-Billing Win Amid Backlog of Payment Disputes - 03/24/2023

Amid much wrangling with federal regulators, the Texas Medical Association is taking steps to hold them accountable for complying with TMA’s second legal victory nullifying certain rules governing out-of-network payment disputes under the No Surprises Act.

TDI Eases Prior Authorization Request Process for Prescription Renewals - 03/20/2023

After a three-year effort, the Texas Medical Association recently secured a form change that allows physicians to bypass the most onerous part of prior authorization requests when renewing an existing prescription.

Medicine Backs Proposed Medicare Prior Authorization Reforms - 02/24/2023

Physicians caring for Medicare patients soon may find relief from onerous prior authorization requirements that frequently delay, discourage, or drive up the costs of care, thanks to proposed regulations governing Medicare Advantage (Part C) and prescription drug (Part D) plans.

UPDATE: TMA Sues Feds – Again – Over Unfair Arbitration Process Under Federal Surprise Billing Rule - 02/10/2023

The Texas Medical Association is back in court – again – to hold federal regulators accountable for implementing a key piece of the No Surprises Act as Congress intended it: to operate an arbitration process that does not skew the dispute resolution process in favor of health plans.