Make Medicaid Managed Care More Efficient

TMA Testimony by Doug Curran, MD

House Human Services Committee
House Bill 4178 by Rep. James Frank 

April 9, 2019

Written Testimony Submitted on behalf of

  • Texas Medical Association 
  • Texas Academy of Family Physicians
  • Texas Pediatric Society
  • American College of Obstetricians and Gynecologists – District XI (Texas) 
  • Texas Association of Obstetricians and Gynecologists 

Chairman Frank, Vice Chair Hinojosa, committee members, I am Dr. Doug Curran, a practicing family physician from Athens, Texas. I am testifying in favor of House Bill 4178, recognizing the bill remains a work in progress. I speak today on behalf of the Texas Medical Association, the Texas Academy of Family Physicians, and the specialty societies representing pediatrics and obstetricians-gynecologists. As a family physician, I see patients from cradle to grave and all stages of life in between. As such, my practice participates in every Medicaid managed care program – STAR, STAR+PLUS, STAR Health, and STAR Kids. I am in a unique position to identify what works and what does not in each product and various plans. It goes without saying that Medicaid is critical to the health and well-being of my patients – and your constituents. At the same time, after a quarter century of Medicaid managed care, it is time for a major tune-up to ensure the program works for everyone – patients, physicians, plans, and the taxpayers.

HB 4178 is the culmination of work by physicians, hospitals, and health plans to reduce Medicaid red tape. Or in the chairman’s vernacular, it will eliminate “monkey movements” – unnecessary and annoying paperwork and administrative hassles that increase costs for everyone while distracting us from our mutual goals of improving patient care.  

Over the past several months, leadership from the associations representing physicians, hospitals, and health plans have collaborated to untangle a plethora of Medicaid Gordian knots. And despite a lot of fussing and cussing – and even a few tears – we’ve made real progress. HB 4178 will modernize outdated Medicaid claims payment requirements, streamline physician and provider enrollment and credentialing, and improve systems of care for medically fragile children to help avoid gaps in care or services.

But there is still much work to do. Of particular concern is reforming the Medicaid managed care organization prior authorization processes. Physicians feel heavily burdened not only by the number of prior authorizations they must complete but also the complexity of the process. The system must be reformed to make it more accountable, transparent, and simpler. Last week, the plans, testifying before this committee on another bill, said they dislike denying prior authorization as much as physicians dislike asking for it. We take them at their word. As such, it is imperative that the state provide clear expectation that the plans will reduce the number of such requests and make it easier for physicians to understand denials when they do occur. We respectfully request revisions to HB 4178 encompassing the following principles: 

  • Eliminate unnecessary prior authorizations – such as for services routinely approved or for services to patients with conditions unlikely to change; 
  • Ensure that denial notices convey precisely what documentation must be submitted to comply with the request and any medical necessity criteria needed to comply. If a physician does not know what is missing or incorrect on the initial request, how is he or she to comply with a second documentation request?
  • Standardize and streamline prior authorization timeframes to promote compliance by all parties;
  • Direct plans to establish a standard three-day grace period following an adverse determination denial. This will allow physicians to submit missing documents or complete a peer-to-peer conversation; and
  • Require managed care plans to provide reasonable after-hours availability for peer-to-peer consultations.

We applaud Chairman Frank for his leadership, and look forward to continuing collaboration with him, the committee, and Medicaid stakeholders as the bill evolves. I also would like to acknowledge that HB 4178 complements reforms found in other Medicaid managed care bills, some filed by members of this committee, and we look forward to continued discussions on the additional measures needed to improve availability of Medicaid services while also eliminating costly red tape and overhead.

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Last Updated On

April 09, 2019

Originally Published On

April 09, 2019