Preauthorization

Health Plans Begin Implementing Prior Auth Exemption Process - 09/28/2022

With an Oct. 1 deadline on the horizon, health plans have begun implementing Texas’ new prior authorization exemption process requiring them to issue the first so-called “gold cards” by that date.

“Gold Card” Final Rules Heed Some, But Not All, TMA Recommendations on Prior Auth Exemption Process - 09/09/2022

Texas physicians have anxiously awaited – and advocated for – relief from onerous prior authorizations, which is now closer than ever.

Aetna Scraps Required Prior Auth for Cataract Surgery - 07/20/2022

Organized medicine’s efforts across the nation to torpedo or curb prior authorization recently got a small but encouraging boost when Aetna rescinded its year-old preauthorization requirement for cataract surgeries.

What's Next for Prior Authorization: Texas' 'Gold Card' Law Winds Through Rulemaking - 06/29/2022

Physician advocates, alongside the Texas Medical Association, are looking to this fall’s legislative races as they monitor the rulemaking underway to implement the "Gold Card" law and prepare to push for additional reforms during the 2023 legislative session that kicks off in January.

Imaging Contrast Shortage Highlights Need for Relaxed Prior Auth - 06/27/2022

A shortage of iodinated contrast media resulting from recent COVID-19 lockdowns in China has put a focus on prior authorization barriers that unnecessarily impede the imaging services patients need to ensure timely care.

Physician-Led Results: Grassroots Advocacy Paid Off in Tangible Wins at the Capitol - 06/15/2022

Texas physicians made the most of an extraordinary, scaled-back session of the Texas Legislature in 2021. They helped pass laws to curb prior authorization hassles; keep physicians from incurring new practice costs; install liability protections for future pandemics like COVID-19; extend postpartum Medicaid coverage for new mothers; and keep graduate medical education (GME) fully funded. And so much more.

Federal Prior Auth Bill Filed in Congress - 06/15/2022

U.S. Rep. Michael C. Burgess, MD (R-Lewisville), is following his fellow Texas physicians’ lead on curbing insurers’ hassle-laden prior authorization burdens, introducing a federal bill similar to the “gold-card” law the Texas Medical Association proposed and championed into law at the state level.

Medicare Advantage Plans Wrongly Denied Prior Auth, Payment Requests, Fed Report Shows - 05/06/2022

About 13% of prior authorization denials in Medicare Advantage likely prevented or delayed necessary care, according to an analysis by the U.S. Department of Health and Human Services Office of the Inspector General. The report also found that nearly one-fifth of the time Medicare Advantage plans denied payment requests when the request met Medicare coverage rules and should have earned approval.

TMA to Feds: Consider Texas Model While Examining Electronic Prior Auths - 03/30/2022

In responding to a federal agency’s questions about the potential impact of electronic prior authorization, the Texas Medical Association – as always – came out strongly against unnecessary prior authorizations in general, while specifically encouraging regulators to advance a version of Texas’ new “gold card” law to curb those practices.

Medicaid Relaxes Prior Authorization for Hep C Antiviral Drugs - 09/06/2021

For years, Texas Medicaid patients with hepatitis C haven’t had access to overwhelmingly effective, often-curative antiviral therapy unless they had advanced liver disease. In many cases, getting the antiviral drugs at that point was too little, too late.

House OK’s Restriction of Prior Auth for Autoimmune Scrips - 04/20/2021

The Texas House of Representatives on Monday passed a bill that severely restricts insurers’ ability to impose preauthorization requirements for prescriptions for autoimmune diseases.

Eliminating Care Delays and Waste in Prior Auth - 04/13/2021

The House of Medicine brought one strong reason after another to Tuesday’s House Insurance Committee hearing on why lawmakers should support a measure that takes two major steps to reduce physicians’ prior authorization burden.  

Legislative Hotline: Chasing the “Gold” on Prior Auth; Gender-Affirming Care - 04/12/2021

The Texas Medical Association is sending three physician leaders to Tuesday's House Insurance Committee hearing to address the hassles and care impediments of health plans’ preauthorization requirements.

Prior Authorization Hassles Almost Always Cause Care Delays, Survey Shows - 04/12/2021

Most physicians know that health insurers’ prior authorization policies delay access to care, often causing serious harm to patients. A survey of physicians taken in December 2020 by the American Medical Association shows just how often prior auth delays occur.

Medical Billing Tax, Prior Auth, Telemedicine Hit Committee Hearings - 04/09/2021

The Senate Finance Committee is scheduled to take a look today at a bill that would protect billing companies from a tax currently scheduled to begin in October – and protect physicians and patients from any of those costs billing organizations pass on to them.

New Tools to Help Medicine Fight Prior Auth Hassles - 04/09/2021

TMA has created a prior auth social media toolkit that includes messages, sample posts, and articles that you can share on your personal or practice social media channels.

Legislative Hotline: Prior Auth for Chronic Disease Drugs Goes Before Insurance Panel - 03/16/2021

Two TMA physicians were scheduled to offer their perspective today to the House Insurance Committee on why the state should pass a bill that generally would bar prior authorizations for prescriptions for autoimmune and chronic diseases.

Streamlining Prior Authorization Burdens - 02/05/2021

Prior authorization of health care services has become a burden and a barrier to physicians providing the care their patients need. Health plans maintain they require prior authorizations to ensure requested services are medically necessary and appropriate. But the escalation of prior authorization use may also be motivated by a desire to control costs.

AMA Advocates for 24/7 Prior Authorization Processing - 11/19/2020

AMA delegates passed new policy on Tuesday that advocates for insurers and benefit managers who require prior authorization to have staff available to process  those approvals 24 hours a day, year-round, “including holidays and weekends.”

Mixed Bag: Some Payers Capitalize on COVID Chaos; Others Help Make Care Easier - 10/30/2020

Physicians believe some payers are taking advantage of COVID chaos with their drug policies, but also see some plans taking steps to make care easier during the pandemic.

Appropriate Use of Time? Medicare Rules for Advanced Imaging Orders Pose Prior-Auth Burdens - 04/09/2020

An effective way to cut down on overuse of potentially harmful imaging, or a prior authorization-esque burden on physicians who order needed tests? Texas physicians see Medicare’s “appropriate use” system for advanced imaging both ways. As of Jan. 1, physicians ordering advanced imaging tests for Medicare patients must consult an electronic portal, which evaluates whether the test meets Medicare’s own “appropriate use criteria” for whether a test should be ordered. Then when the claim is filed, physicians must document that they checked the system and its determination.  

Plans Should Inform Patients of Network Status When Requiring PA - 03/25/2019

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

Medicine to Feds: Back Off Prior Authorization Requirements - 03/07/2019

The Texas Medical Association, American Medical Association, and a host of other medical societies are trying to stop onerous, care-impeding prior authorization requirements from overrunning Medicare Advantage plans.

Humana Peer-to-Peer Review Changing for Medicare Advantage Plans - 10/05/2018

Effective Aug. 1, Humana Medicare Advantage health plans will no longer offer peer to peer reviews after a medical necessity denial. Instead, the company will offer to schedule a peer-to-peer review before Humana issues the denial

TMA Delegates Push Back Against Preauth - 05/30/2018

The Texas Medical Association House of Delegates worked to recover the time and authority that insurance authorization and preauthorization requirements have increasingly taken from the state’s physicians.