Insurance

Out in the Cold: Health Plan Blamed For Major Prompt-Pay Mess - 05/01/2019

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.


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.


Preserve Physician Liability Protections in Emergencies - 04/09/2019

We are very concerned about how this bill will damage Texas’ ability to attract and sustain highly trained, competent doctors, including obstetricians and gynecologists, and specialty doctors such as maternal fetal medicine physicians and urogynecologists. This bill will hamper physicians’ ability to make ethical and professional decisions in the best interest of their patients for fear of repercussions.


Pharmacy Benefit Management System Needs Reform - 04/02/2019

Coordination between the doctor and the pharmacy such as in a medically integrated pharmacy becomes very important when using oral therapies that are high cost and have potentially high toxicity.


Enforce Network Adequacy - 04/02/2019

The median number of managed care contracts a physician has continues to decline. Physicians want to be in-network. When in network they receive a patient base for care, they do not have to chase down their payments, and a health plan is subject to prompt pay penalties. We believe Representative Vo’s bill will assist in strengthening network adequacy oversight and ensure the patients of Texas are receiving the coverage for which they are paying.


Prohibit Step Therapy in Metastatic Cancer - 04/02/2019

In some diseases, step therapy may not have severe consequences when patients’ symptoms are less controlled or a disease has moderate control. Metastatic cancer therapy requires protection from these utilization management techniques as the consequences of less control are grave.


Prohibit PA on Mandated Benefits - 03/26/2019

HB 2408 recognizes the many negative effects of prior authorization requirements and takes the commonsense approach of prohibiting prior authorization requirements with regard to certain services that are part of a plan’s mandated benefits under state law. If a health plan must cover these medical services by law, it makes little sense to permit the plan to subject these services to its prior authorization process. With regard to the mandated benefits covered in this bill, prior authorization would seem to serve little purpose other than delaying medically necessary care or deterring a patient from seeking medically necessary covered care.


Expand Access to Care to All Texans Who Need It - 03/06/2019

Uninsured patients often skip cost-effective primary and preventive care, self-medicating or ignoring signs of chronic illness. Sick children cannot go to school, harming their ability to learn. Sick parents cannot work, harming their earnings and buying power. Sick employees contribute to higher absenteeism and decreased productivity, thus lower profits. Ultimately, all Texans pay.


Expect HEDIS Records Requests From Third Parties - 02/28/2019

If a company called Ciox Health contacts your office on behalf of Blue Cross and Blue Shield of Texas or UnitedHealthcare, it is because both insurers have contracted with Ciox to collect performance data they are required by law to report.


Humana Changes for 2019: Preauthorization, Notification, and Formularies - 02/27/2019

Humana has made changes for 2019 to its preauthorization and notification lists.


Help Eliminate Patients’ Insurance Confusion - 02/06/2019

The Texas Medical Association has launched a comprehensive agenda for health insurance reform with the Texas Legislature. In the meantime, TMA is offering a new continuing medical education (CME) course to help you help your patients.


Texas' High Rate of Uninsured Hurting the Economy, Study Says - 01/16/2019

Texas has the highest percentage and number of people without health insurance in the United States, which could cause long-term damage to the state’s economy, says a study released this week by the Texas Alliance for Health Care.


Health Care Leaders Host First-Ever Joint Summit on Texas Medicaid - 01/09/2019

As the future of Texas Medicaid promises to be a central topic of discussion in the 86th Texas Legislature, leaders from three pillars of the Texas health care system gathered in Austin on Oct. 12 for a first-ever summit to identify and commit to working on shared priorities for strengthening the program.


Review Your Physician Compare Data Before Jan. 7 - 12/20/2018

The Centers for Medicare & Medicaid Services (CMS) recently opened its Physician Compare preview period, which will allow you to check out your 2017 QPP performance data and 2016 clinician utilization data before it’s publicly reported on Physician Compare in early 2019. CMS will close the preview period on Dec. 31, so you’ll want to review your information and check for errors as soon as possible.


Sharing is Caring? Health Care Sharing Ministries Cause Confusion - 12/07/2018

Confusion surrounding health care sharing ministries puts Texas Medical Association on alert.