Feb. 13, 2025
Health Plans’ Routines Deny, Delay Patients’ Care
The Texas Medical Association (TMA) seeks to cut health insurers’ burdensome delays and denials of patients’ care this legislative session. When physicians treat insured patients, they often need approval from the health insurance company for medications, tests and procedures, in a practice called prior authorization. Physicians say too often the process delays and denies patients’ care.
“When we're seeing patients in our office settings or in the hospital, we usually are making fairly quick decisions in the basis of people's health,” said Tony Aventa, MD, an internist in Austin and member of the TMA Board of Trustees. “When we have to run decisions by an insurance company, that can get in the way of providing appropriate care in a timely manner.”
Prior authorization
reform is one of TMA’s top priorities this legislative session. “I think we need to
take some black and white, pretty straightforward decisions to step back prior
authorization as a tool,” said Dr. Aventa.
Nearly all – 94% – of physicians said prior authorizations
delay access to necessary care, according to 2023 American Medical Association survey. Nearly
one in four said the process led to serious adverse events ranging from
hospitalization to death.
Timothy Parker, MD, a Denison gynecologist and vice chair
of TMA’s Council on Legislation, said one of his patients suffered because
her health insurance company denied her medication for endometriosis – a
chronic condition that causes severe menstrual pain. The plan demanded
additional studies and documentation; after he provided that, they denied the
medication anyway.
Dr. Parker said the patient had to wait for over two months
as he appealed the prior authorization denial. “This poor patient is having
horrible menstrual cramps, horrible pain. It is just absolutely ridiculous to
have to put up with this,” he said.
Health plans used to place fewer prior authorization demands
on physicians and patients, Dr. Aventa said, but now they are routine. Insurance
companies are reviewing medications even when they're straightforward
medications and sometimes generic medications,” he said.
When health plans delay or deny patients’ medication or
procedure, patients are forced to either pay out of pocket or forego the medical
care they need – despite also paying for health insurance.
To reduce prior authorization hassles, TMA worked
with lawmakers to pass the Texas “gold card” law in 2021. The law
exempts physicians from an insurer’s prior authorization requirements for a
particular service if they receive approvals on at least 90% of their requests
for that service during a six-month period. This would help avoid delays in
patient care. However, health plans have found ways to circumvent the law, so
implementation has been slower than planned; physicians and patients are not
seeing the full benefits yet.
“The intention was absolutely great, but … [the] insurance
companies are always going to find a way around it,” said Dr. Parker.
To reduce the burden of prior authorization on physicians
and their patients TMA is supporting the following measures:
- Senate
Bill 547, which builds on the 2021 gold carding law framework and promotes its
implementation as originally intended with additional transparency and
accountability standards for insurers.
- Senate
Bill 177/House Bill 2150 and Senate Bill 815 to require health plans to approve
patient care and verify coverage in a timely manner and to prohibit health
plans from using fully automated systems to deny care.
- House
Bill 1818 that requires the Texas Department of Insurance to conduct reviews of
health plan compliance with requirements related to utilization review at least
once annually.
- Streamlining
prior authorization for cancer treatments and chronic conditions similar to
what 2023’s House Bill 755 did
for some autoimmune diseases and blood disorder drugs.
- Initiatives
to ensure denials or delays in care do not lead to avoidable medical
emergencies.
TMA is the largest state medical society in the nation,
representing more than 59,000 physician and medical student members. It is in
Austin and has 110 component county medical societies around the state. TMA’s
key objective since 1853 is to improve the health of all Texans.
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TMA Contacts: Brent Annear (512) 370-1381; (512) 656-7320
Swathi Narayanan (512) 370-1382; (408) 987-1318
Connect with TMA on Twitter, Facebook, Instagram, and LinkedIn.