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2023 Legislative Preview: TMA's Top 10 Priorities
Goal: Build on the success of last session’s “gold card” law by advancing prior authorization reform
Impact: The 2021 “gold card” law, spearheaded by the Texas Medical Association and passed by the Texas Legislature after years of advocacy spanning multiple sessions, represented a huge step toward prior authorization reform. It also positioned Texas as a leader, with other states already advancing their own copycat legislation.
While the new process appears to be working for many physicians, there’s still work to be done to ensure eligible health plans are held accountable under the new law, says TMA lobbyist Ben Wright. So, the association is vigilantly monitoring the implementation process and seeking modifications to close any loopholes. It also continues to push for additional reforms.
Under the new law, which took effect Oct. 1, 2022, physicians who earn approvals on at least 90% of prior authorization requests for a given service or medication can earn a “gold card” exempting them from onerous preapproval requirements for that service or medication.
TMA has learned, however, many gold cards did not go out on time. Chris Kean, chief operating officer of TSAOG Orthopaedics & Spine in San Antonio, noticed physicians in her practice weren’t receiving them as often as expected.
“We did receive some exemptions for some of our physicians for some payers,” she told Texas Medicine. “But, because of the way the [Texas Department of Insurance (TDI) regulations] were written, it’s made it very difficult for physicians to qualify for an exemption.”
For instance, to be eligible for an exemption, many health plans require physicians to submit a minimum of five prior authorization requests for each service code – say, an MRI of a knee – within the six-month review period. Ms. Kean says this means many physicians don’t meet the threshold for review, even if they request authorization for more than five MRIs overall. (TMA had advocated during rulemaking for no minimum, as none was set forth in the law.)
San Antonio radiologist Zeke Silva, MD, who serves on TMA’s Council on Legislation and testified on the original legislation, says this kind of feedback is critical.
“TMA listens to the needs and experiences of physicians in how this law is affecting them, what’s working with the law, what could be improved with the law, and how we can improve that through the statutory or regulatory process,” he said.
Although precedent-setting, the gold-card law is not a panacea for physicians’ prior authorization woes given that it only applies to state-regulated plans, which account for about 20% of the Texas market.
As a result, Clayton Stewart, TMA’s vice president of public affairs and chief lobbyist, says the association expects to revisit the issue this session.
Other TMA priority legislation includes requiring health plans to provide 24/7 prior authorization processing, including on holidays and on weekends, and eliminating prior authorizations altogether for patients with autoimmune disorders, who often must wait for health plans’ approval each time their prescriptions are renewed.
Despite her concerns, Ms. Kean is proud of Texas for being the first state in the country to enact the gold-card legislation and remains optimistic for any fixes.
“It’s a tough job for trailblazers,” she said. “But I’m up for it.”