The House of Medicine’s biggest tool left in this year’s legislative session to curb prior authorization passed the Senate last weekend but with an overhaul of the system that would exempt physicians from preauthorizations for certain services.
At press time, an amended version of House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), also known as the “gold card” bill, was back in the hands of the House, which must agree with the changes in order to send this version to Gov. Greg Abbott’s desk.
A “gold card” refers to physicians earning their way out of the prior authorization rigmarole by demonstrating a high prior auth success rate. Under the new version of HB 3459:
- Physicians who see prior authorizations for a given service approved at a 90% clip would earn their gold card for that service, up from 80% in the previous version.
- The gold card would be a continuous one, instead of physicians being able to earn one every other year as in the previous version.
- In January and June of each year, insurers would be able to reevaluate gold card-holding physicians over the previous six months with a retrospective review of between five and 20 claims. If the review shows that less than 90% would have been approved based on medical necessity, the health plan may rescind the physician’s gold card.
- The rescission would take effect after 30 days if the physician doesn’t appeal it. A physician’s appeal would go to an independent review organization (IRO). If the IRO upholds the health plan’s decision to revoke the gold card, it would take effect five days after that decision.
HB 3459 also addresses utilization reviews, requiring that a person performing one for a health plan must be a Texas-licensed physician in the same or similar specialty as the patient’s physician who requested the service.
Crunch-time update: Medicare collaborative-care bill ready for signature
With just six days left before adjournment, here’s an update on several measures the Texas Medical Association is trying to push toward the finish line, or steer back on course before final passage. As of early Monday:
Senate Bill 672 by Sen. Dawn Buckingham, MD (R-Lakeway), to require Medicaid to pay for collaborative care codes passed the House Sunday and now can head to Governor Abbott’s desk.
Senate Bill 248 by Sen. Nathan Johnson (D-Dallas) to establish a licensing and regulation framework for e-cigarette dealers is on the House calendar for today.
House Bill 133 by Rep. Toni Rose (D-Dallas) was medicine’s vehicle to establish one year of continuous coverage for women in Medicaid postpartum. However, the bill on Monday’s Senate intent calendar included just six months of coverage. TMA hopes to restore the 12-month time frame if the bill passes the Senate and reaches a conference committee.
House Bill 290 by Rep. Philip Cortez (D-San Antonio) to establish six months of continuous eligibility for children in Medicaid, with an eligibility check for another six months of coverage, passed the Senate Health & Human Services Committee last Friday. TMA was trying to resolve questions it had about the most recent version of the bill.
House Bill 4272 to improve the state’s immunization registry passed out of the Senate Health & Human Services Committee last Thursday, sending it to the House floor. However, as with HB 290, language was recently added to the bill – in this case, prohibiting governments and businesses from implementing “vaccine passports.”