Insurance

Send TMA Your Prior Auth Nightmare Stories - 09/18/2019

Arbitrary. Confusing. Frustrating. Never-ending. Maddening. Those are some of the terms we can actually print that describe physicians’ perceptions of insurance companies’ prior authorization requirements and approval processes. Your personal stories of patient harm due to prior authorization request delays or denials can give the Texas Medical Association the ammunition it needs to fight this problem. Please submit your stories via email to the TMA Payment Advocacy Department.


An Insurance Company Auditor Tried to Destroy My Career - 09/16/2019

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.


Gender-Neutral Insurance Rates = Big Savings for Women Physicians - 09/05/2019

To help Texas Medical Association members get the income protection they need, the exclusive TMA Member Long Term Disability Plan, issued by The Prudential Insurance Company of America, uses group rates that are based on age, not gender. Female physicians will find these gender-neutral group rates significantly less expensive than most individual disability plans available in Texas.


Are You Eligible for “Expedited Credentialing?” - 08/28/2019

If you’re completing health plan credentialing, “expedited credentialing” might apply to you. And if it applies, that could be good for you and your practice. But how do you know if it does?


Tell Congress: Protect Patients, Not Health Plans - 08/16/2019

Our U.S. senators and representatives are back home in Texas for the August recess, and Texas Medical Association President David Fleeger, MD, says their physician-constituents need to contact them to make sure they stop the surprise medical billing epidemic in a way that helps our patients – not big insurance companies.


Payers Axe Consultation Codes - 08/07/2019

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.


Out in the Cold: Health Plan Blamed For Major Prompt-Pay Mess - 08/02/2019

Molina Healthcare of Texas isn’t the only insurer to give physicians prompt-pay problems, and it won’t be the last. Some of the practices trying to recover payments blame not just the health plan, but also the extended response time from the state regulator overseeing insurance products and conduct: the Texas Department of Insurance, which says it’s hiring staff and making other changes to improve that response.


Insurance: Network Solutions - 08/02/2019

Charting Medicine’s Statehouse Progress TMA went into this session looking to attack insurer network inadequacy and health plans’ use of care impeding prior authorization demands. On both fronts, medicine scored solid legislative wins that will make it


TMA President: Rulemaking on Surprise Billing Must Be Fair to Docs - 07/31/2019

Now that the Texas Legislature has passed a measure to counteract surprise billing involving many state-regulated plans, it’s time for rulemaking. The Texas Medical Association is working to make sure the Texas Department of Insurance’s eventual rules borne out of Senate Bill 1264 will give physicians a fair shake.


Turn to TMA to Resolve Prompt-Pay Issues - 07/22/2019

If you or your practice is dealing with prompt-pay or other health plan problems, the Texas Medical Association can help resolve those issues through TMA’s Hassle Factor Log program. The Texas Department of Insurance last week released a bulletin reminding plans that a portion of prompt-pay penalties must be paid to the state.


Panel Makes Big Change in Draft Federal Surprise Billing Law - 07/17/2019

Thanks to incessant lobbying from physicians, hospitals, organized medicine, and the Physicians Advocacy Institute, a key congressional committee today made significant revisions in a bill to reduce the strain of surprise billing on patients. “This certainly sounds like an improvement,” said Texas Medical Association President David Fleeger, MD, “but the devil will be in the details.”


TMA Pushes to End Surprise Bills – The Right Way - 07/10/2019

TMA’s chief lobbyist is working Capitol Hill this week to pass a bill that spares patients the pain of surprise bills but doesn’t give health insurance companies complete control over what it pays physicians who treat patients out of network.


Health Care is Difficult to Afford, More Than Half of Texans Say - 07/02/2019

Health care is the toughest living expense for most Texans to afford, and many skip or postpone tests, medications, and basic procedures because of the cost. And that very well could be bad for their health, especially for the millions who lack insurance. Those are the findings of a statewide poll on the affordability of and access to health care in Texas published last month by the Episcopal Health Foundation.


TMA: No Government Price Controls for Out-of-Network Billing Disputes - 06/25/2019

The government shouldn’t set the fees physicians are paid for out-of-network care. That’s the message the Texas Medical Association is sending to key members of the U.S. Senate as lawmakers consider a troubling federal bill.


Medicine to CMS: Medicare Report Inflates Success of Quality Program - 05/01/2019

If you read the recent Centers for Medicare & Medicaid Services (CMS) report on the first-year of the Quality Payment Program, you’d likely come away with the perception that the program’s launch was an overwhelming success. But a closer look by the Texas Medical Association raises serious doubts about CMS’ numbers, transparency, and cheerleading – so much so that TMA and seven other state medical associations are asking the agency to take back the report.


TDI Fines Molina Healthcare $500,000 in Prompt-Pay Order - 04/30/2019

The Texas Department of Insurance (TDI) has fined an insurer whose inability to pay claims on time kept physicians waiting on millions of dollars. TDI dealt Molina Healthcare of Texas an administrative penalty of $500,000 – on top of almost $8 million combined that the insurer paid in penalties and interest to TDI, and to affected physicians and other health care providers.


Dos and Don’ts of Using Modifier 22 - 04/25/2019

Sometimes the work to provide a service is “substantially greater” than typically required on the date of services. When this happens, document the extra work by adding modifier 22 to the procedure code.


Charging Concierge Fees to BCBSTX Patients - 04/23/2019

Although Blue Cross and Blue Shield of Texas (BCBSTX) places limits on the additional fees participating network physicians can charge BCBSTX patients, some are allowed when you provide concierge services.


Go Paperless With UHC Document Vault - 04/22/2019

Looking for ways to reduce the amount of paper your practice uses? One way is to digitally receive claim and prior authorization letters for UnitedHealthcare commercial and Medicare patients through UHC’s Document Vault, rather than by mail.


More Than 1 Million More Texans Could Be Covered, Report Shows - 04/18/2019

Expanding Medicaid coverage under the Affordable Care Act would help put a substantial dent in the number of uninsured Texans, a new report by the Kaiser Family Foundation shows.


Ambetter: New Required Field on CMS-1500 Claim Form - 04/18/2019

Ambetter from Superior HealthPlan, a plan available on the Affordable Care Act health insurance exchange, has changed the status of box 18 on the CMS-1500 claim form from a conditional/optional field to a required one, effective July 1.


TMA Pushes for Prior Authorization Limits, Clarity - 04/17/2019

After hearing story after story of delays and denials, the Texas Medical Association is pushing the Texas Legislature to sign off on measures that would significantly curb insurers’ ability to require prior authorization on needed care, as well as clarify for both physicians and patients what it means when prior authorization is required.


Medical Debt and Credit Reports - 04/16/2019

While we are working to remove the patient from disputes between the insurance carrier and the physician, simply preventing the physician from seeking payment options for care already rendered despite the patient’s insurance not covering the service is placing the burden and the penalties in the wrong place. For these reasons, we cannot support HB 2732.


Transparency in Prior Auth and Physician Referrals - 04/15/2019

When a patient is preauthorized to receive a health care service scheduled at a facility, the health plan should use the information on the form to inform the patient of the network status of any physicians or health care providers who may be involved in the preauthorized care. The health plan also should use the information to tell the patient what level of coverage the plan will be provide and what the patient’s financial responsibility will be to all physicians and providers.


Eliminate Prior Auth for In-Network Physicians - 04/15/2019

Prior authorization is often very burdensome and can present a significant impediment to optimal patient care. Prior authorization can cause delays in medically necessary care, which may detrimentally affect patient health and finances. Excessive prior authorization requirements also create administrative hassles for physicians and consume time that otherwise would be devoted to patient care.