Utilization Reviews Should Be Done by Texas-Licensed Physicians

TMA Testimony by Doug Curran, MD

House Insurance Committee
House Bill 2387 by Rep. Greg Bonnen, MD 

March 26, 2019

Thank you, Mr. Chairman and committee members, for allowing me to testify today. My name is Dr. Doug Curran. I am a family physician from Athens, Texas, and president of the Texas Medical Association. Today I am testifying on behalf of TMA and its nearly 53,000 members across the state of Texas.  

House Bill 2387 is an important bill that is directed at ensuring appropriate accountability to the state of physicians and health care providers involved in the performance of utilization reviews for health plans and utilization review agents.

Utilization review is a cost-saving tool used by health insurance companies and health maintenance organizations. It is a system through which payers review the medical necessity and appropriateness of health care services provided to patients. A utilization review can involve a review before care is provided (which is called “preauthorization”), at the time care is provided, or after care is provided. 

Utilization review occurring before a patient receives care can be very burdensome administratively and can delay medically necessary care or alter the physician’s treatment plan for the patient (thereby having significant health consequences for patients).   

A few statistics that were recently released by the AMA indicate that:

  • Twenty-eight percent of physicians reported that prior authorization has led to a patient having a serious adverse event; 
  • Seventy-five percent of physicians report that prior authorization can lead to patient treatment abandonment; and
  • Ninety-one percent of physicians reported prior authorization creating a significant or somewhat negative impact on patient outcomes. 

Given the serious impact this type of utilization review may have on a patient’s care and that adverse determinations made by a health plan or utilization review agent effectively override the medical judgment of the patient’s physician, it is imperative that utilization review programs be directed by physicians who are licensed by and accountable to the Texas Medical Board. It is also imperative that any adverse medical necessity determinations involving physician care be made by Texas-licensed physicians.  

Current Texas law requires a utilization review agent to conduct such review under the direction of a physician, but allows that physician to be one licensed by a state licensing agency in the United States (rather than by the Texas Medical Board). The Utilization Review Act also has many requirements for the involvement of physicians in utilization review; however, it does not expressly reference Texas licensure in those provisions. Thus, some utilization review agents have used physicians licensed outside of Texas. 

HB 2387 is directed at making express in both the Utilization Review Act and the Medical Practice Act the state licensure requirements of physicians making adverse determinations in utilization reviews.  

Determining whether or not a physician’s recommended medical service is needed is the practice of medicine; therefore, physicians making these determinations need to be held accountable to the Texas Medical Board just as the treating and ordering physicians are.  

HB 2387 also requires either same or similar-specialty reviews by Texas-licensed physicians.  We think this is imperative to avoid improper denials of preauthorization requests and delays in medically necessary care.   

Patient care should always be the primary focus, rather than a bottom line for the health plan.  HB 2387 is appropriately focused on this goal.  

86th Texas Legislature Letters and Testimonies

TMA Legislative main page

Last Updated On

March 25, 2019

Originally Published On

March 25, 2019

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