TMA Pushes for Prior Authorization Limits, Clarity
By Joey Berlin


Enough of the roadblocks. Enough of the hassles. Enough of the delays in care. 

Enough, enough, enough. 

That’s what physicians have been saying ever since prior authorization (PA) demands proliferated in recent years into relentless instruments of care obstruction. 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 PA on needed care, as well as clarify for both physicians and patients what it means when PA is required. 

The legislature is listening, with committees recently signing off on some of TMA’s priority PA legislation. 

"Prior authorization often leads to a delay of much-needed care and, at times, may result in a denial of medically necessary care altogether,” Rep. Julie Johnson (D-Carrollton), who introduced a bill that would disallow prior authorization requirements for state-mandated health plan benefits, told Texas Medicine Today

“Prior authorization may undermine a physician’s treatment plan and the physician’s judgment as to the best care for his or her patient,” Representative Johnson said. “At a time when Texas ranks 50 out of 50 on the insured rate, rather than create barriers we should be incentivizing Texans to procure coverage." 

Austin oncologist Debra Patt, MD, says while prior authorization is an important part of utilization management, “it’s become so cumbersome in the last five years that most of us have had to triple our staff in order to manage prior authorization. The pendulum has swung in a very different direction [such] that we need to try to rein it in and make sure it is used when most appropriate.” 

Two of the legislature’s physicians have authored a TMA-backed measure that would bring much-needed clarity to the PA process. HB 2327 by Rep. Greg Bonnen, MD (R-Friendswood), and its companion, Senate Bill 1186 by Sen. Dawn Buckingham, MD (R-Lakeway), would require HMOs and insurers to post on their websites, in plain language, “a list of the health care services for which the [HMO or insurer] requires preauthorization,” and how it works. That includes a list or description of documentation physicians must provide as part of the process. 

On March 26, TMA President Doug Curran, MD, testified in favor of HB 2327. Dr. Curran told the House Insurance Committee that prior authorization hurdles are “probably one of the biggest banes of my existence,” and that patients get sick of it, too. 

A 2018 American Medical Association survey on prior authorization found that practices spend an average of almost two business days each week completing PAs, and 28% reported that PA “led to a serious adverse event.”

Dr. Curran told the committee the story of one patient who came in with shortness of breath and chest pain. Dr. Curran realized he needed to give her an arterial CT scan to check for a pulmonary embolism or a blood clot.

“And I need to get that done fairly quickly. There is no way. I mean, it takes forever to get that done,” Dr. Curran told the committee. “So I have to send her to the emergency room and get her checked in to the emergency room. I could have done all this [with her classified] as an outpatient, saved everybody money, got everything going.” 

As it turned out, Dr. Curran explained, the patient didn’t have a pulmonary embolism; she had necrotizing pneumonia and ended up in the hospital anyway. 

“But a lot of that could’ve been taken care of as an outpatient,” he testified. “And that’s just what we do every day, trying to sort through this.” 

HB 2327 “would be a tremendous help,” Dr. Curran testified, and would “significantly improve our circumstance.” 

Both versions of the bill originally contained a provision that would exempt physicians from prior authorization requirements if their PA requests have been “routinely” approved. The Texas Department of Insurance would establish rules for exemption. That language is still in Senator Buckingham’s version of the bill. 

“If 90 percent of your prior authorization requests are approved, then why do you have to keep doing that and keep doing that and keep doing that?” Senator Buckingham told Texas Medicine Today. “The idea is to increase that access to care for the patients.” 

Meanwhile, House Bill 2408 by Representative Johnson and Senate Bill 1741 by Sen. Jose Menendez (D-San Antonio) take aim at a different angle of aggravation for physicians and patients: Prior authorization requirements for state-mandated health plan benefits. The bills would eliminate prior authorization for procedures such as mammography, mastectomies, prostate cancer screenings, and diabetes equipment and supplies, if a health plan is required to cover those benefits. 

HB 2408 also earned a hearing in the House Insurance Committee on March 26, where Dr. Patt testified in support. She says it makes no sense to implement prior authorization on a procedure that the law requires insurers to cover. 

“It’s unnecessary. It’s like saying that you have to stop at a stop light when there is a green light there,” Dr. Patt told Texas Medicine Today. “It’s inherently contradictory, because these things like mammography and breast surgery and breast cancer reconstruction are mandated by the state that they’re paid for. So they shouldn’t be subject to the prior authorization process. It’s a waste of administrative resources, clinical resources, and causes inappropriate delays in appropriate care.” 

HB 2327 passed out of committee on April 2 without the language allowing for physician exemption for PA requirements. HB 2408 passed out on April 2. The companions for both bills have been referred to the Senate Business & Commerce Committee.

Last Updated On

April 16, 2024

Originally Published On

April 17, 2019