Physician-Led Results: Medicine Earns Its Gold Star on Insurance Bills
By Joey Berlin

When it came to addressing prior authorization burdens this legislative session, the Texas Medical Association asked physicians directly what they needed, and those responses helped medicine attack the problem with a laser-like focus.

In one of TMA’s most gigantic wins in the insurance realm, let alone the 2021 session, Texas physicians will soon be able to earn a “gold card” exempting them from the preauthorization roadblocks of state-regulated health plans. And the Texas bill is quickly becoming a model for other states.

Under House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), physicians can earn a continuous gold card by earning approvals on at least 90% of their preauthorizations on a given service over a six-month period.

 “There’s no question that the gold-carding item will be very helpful for physicians to save a massive amount of time for them and for their office staff in not having to get prior authorizations on so many things, every single day and every single week,” said Houston emergency physician Diana Fite, MD, TMA’s president through mid-May 2021. “That will help not only the physicians and their office staff, but help immensely [patients’ ability] to get the care that they need in a timely fashion, and not have them sometimes give up on getting the care because of the frustration of the delays.”

The ability for physicians to effectively test out of prior authorization could be an enormous administrative boon for doctors like internist Lisa Ehrlich, MD, who testified for TMA on behalf of HB 3459 during this session. She says in the past five years, health plans have required prior authorizations “across the board” for just about everything. She’s collected years of aggravating anecdotes involving health plans delaying and denying care through preauthorization.

One that sticks out to her: a patient who had appendicitis on the eve of a major storm’s arrival. The patient got a CT scan at the hospital, then headed to the emergency department (ED) for surgery where she waited 12 hours for her prior authorization to come through. Her appendix ruptured in the waiting room, and she ended up having to stay in the hospital during the storm, plus an additional two weeks.

“Acute appendicitis is not that hard to diagnose; [it’s] pretty easy,” Dr. Ehrlich said. “Basically, the insurance companies are getting in the way saying, ‘OK, you have to prove to us the patient has appendicitis at first through the CT scan, and then you have to prove he needs a CT scan to prove that they have appendicitis. Then it just goes on and on. Virtually right now everything is requiring prior authorization.”

Although the gold card will be continuous after it’s initially granted, health plans will have the opportunity to reevaluate physicians’ status up to twice each year and must notify the physician at least 25 days before a rescission would take effect with a chance to appeal to an independent review organization.

But HB 3459 didn’t just allow physicians a needed path out of the preauthorization rigmarole. It also included language representing something that’s become a white whale for medicine: making sure physicians who conduct peer-to-peer calls for insurers’ utilization reviews are (1) licensed in Texas, and (2) know what they’re talking about.

The new law requires peer-to-peer calls occurring prior to a utilization review denial to be conducted by a Texas-licensed physician in the same or similar specialty as the physician who requested the service. That means no more trying to explain the appropriateness of a procedure to some out-of-state physician in an unrelated subspecialty.

It was physicians who helped make that crucial piece of the bill happen by responding to lawmakers through TMA’s Grassroots Action Center. 

“Does it seem right that an OB-Gyn specialist from Maryland can tell a board-certified neurosurgeon in Texas with over 22 years of experience that an MRI scan of the cervical spine for a patient with arm pain, numbness, and weakness is not necessary?” one neurosurgeon rhetorically asked in an Action Center message to a lawmaker. “I will have to change my practice patterns if there is no relief from prior-authorization hassles, which will mean less care for Texans.”

TMA lobbyist Clayton Stewart says both the gold-card and the utilization review pieces of the bill have real potential to lessen prior authorization burdens “because the concepts in the bill were taken from our physician-members – what they said would be helpful to them, help them get their patients the care they need when they need it.”

While Representative Bonnen carried the ball for HB 3459 in the House, another physician lawmaker, Sen. Dawn Buckingham, MD (R-Lakeway), spearheaded the bill’s advance in the upper chamber.

Bill me never: Tax averted, and other wins

Meanwhile, TMA also scored a major insurance win with the first bill Gov. Greg Abbott signed during this year’s session, which declassified medical billing services as insurance services.

That simple designation in landmark House Bill 1445 by Rep. Tom Oliverson, MD (R-Cypress), meant that outsourced medical billing services won’t be subject to a tax that was slated to take effect in October. Medical billing companies would have passed the added costs onto physicians, and patients would have seen a ripple effect reach their wallets as well.         

Comptroller Glenn Hegar had previously examined state insurance law and decided in 2019 that medical billing services were considered insurance claims processing. Originally, the medical billing tax was set to go into effect on Jan. 1, 2020, but advocacy from TMA helped win two delays, pushing back implementation until after this year’s session. That gave TMA, with the comptroller’s help, a chance to craft a legislative fix.

“This is an example of good advocacy. The only reason this happened is because ...  TMA reached out to me before session, explained the problem to me,” Representative Oliverson told Texas Medicine. He said he called the comptroller and was able to “explain our side and why this was really problematic for smaller practices that don’t have their own in-house billing company. [The comptroller] was very willing for us to fix it legislatively. None of that would’ve happened, though, without TMA advocacy.”

Other medicine-supported insurance wins from this session include:

  • In an effort to increase payer transparency, House Bill 2090 by Rep. Dustin Burrows (R-Lubbock) authorizes the creation of an all-payer claims database through the Center for Healthcare Data at UTHealth in Houston. The database will include claims data, contracted rates, and other information.
  • Senate Bill 827 by Sen. Lois Kolkhorst (R-Brenham) generally caps patient cost-sharing for prescription insulin at $25 per prescription for a 30-day supply.
  • Senate Bill 1028 by Sen. Joan Huffman (R-Houston) lowers the minimum age at which health plans are required to cover colorectal cancer screenings to 45, instead of 50.
  • Senate Bill 1065 by Sen. Carol Alvarado (D-Houston) requires health plans to cover screenings for dense breast tissue at the same level as mammography.

Last Updated On

June 22, 2021

Originally Published On

June 22, 2021

Related Content

Insurance | Texas legislation