Medicine’s push for the Texas Legislature to crack down on insurers’ onerous prior authorization requirements kicks into high gear Tuesday. And it begins with a measure the Texas Medical Association sees as basic, unassailable common sense.
If the state requires coverage for a procedure, TMA believes there’s no reason why a health plan should mandate prior authorization for that procedure. Yet it happens.
So TMA physicians will testify Tuesday before the House Insurance Committee in support of House Bill 410 by Rep. Julie Johnson (D-Carrollton).
The bill is simple: For procedures, tests, and diagnostic treatments that are state-required coverage, insurers may not impose prior authorization. Among other types of care, that would include mammography, certain diabetes equipment and supplies, mastectomies, and other reconstruction procedures.
Little Elm internist John Flores, MD, will be among TMA’s testifying physicians. He plans to tell the Insurance Committee how prior authorization requirements have created care-impeding hassles that affect his diabetes patients. Dr. Flores told Texas Medicine Today about 50% to 60% of his practice is related to treating Type 2 diabetes.
“The new classes of medicines that are now available are able to treat patients in a more holistic fashion,” said Dr. Flores, past chair of TMA’s Council on Socioeconomics. “They get blood sugar down without hypoglycemia. Patients tend to lose weight. They feel better, they have more energy, and at the same time, they have decreased cardiovascular and renal complications.
“Studies have shown that if patients are started on the appropriate medicines when they’re first treated, they tend to stay under control longer and have less treatment failures.”
But almost every time he writes a scrip for one of those medicines, Dr. Flores faces a prior authorization.
“We are basically being second-guessed over and over again,” he said. “In most cases, these prior authorizations are approved. However, during the time waiting for approval, patients may be without medicine. Some frustrated patients will even abandon their treatment.”
HB 410 is the first TMA-supported prior authorization bill this session to get a hearing, but it’s just one piece of TMA’s broad offensive on the practice. Other measures targeting preauthorization and related issues include:
- House Bill 907 by representative Johnson, which would generally ban prior authorizations for prescription drugs to treat chronic or autoimmune diseases.
- House Bill 2142 by Rep. Hubert Vo (D-Houston), which would require the Texas Department of Insurance to conduct once-a-year exams of health insurers’ preauthorization requirements to make sure the health plans are complying with laws governing prior authorization.
- House Bill 2035, also by Representative Johnson, which would make it a deceptive trade practice for insurers to violate the prudent-layperson standard for emergency care; to deter health-plan enrollees from seeking care consistent with that standard; or to engage in a pattern of wrongful denials for emergency care.
Meanwhile, work continues on other as-yet-unfiled legislation on preauthorizations: One proposal would “gold-card” physicians out of the prior authorization process if they reach a certain threshold percentage of approved preauthorizations. Another would require insurers to provide a physician of the same or similar specialty as the requesting physician for “peer-to-peer” phone calls.
“In my work as chair of [TMA’s Council on] Socioeconomics, I met with health plan representatives many times about prior authorization,” Dr. Flores said. “Their feeling was, without prior authorization, there were some physicians out there that would not hold themselves to the standards they expected, and they did not want to give up that control. They would rather hassle 95% of the physicians that are doing it right to control that 5%.
“The health plans are using prior authorization to hassle our patients and most of our colleagues to keep costs down – without evidence that doing so improves the quality of care.”
Send TMA Your Prior Auth Nightmare Stories
Your personal stories of the impact of prior authorization requirements on your practice and patient care – including any patient harm due to prior authorization request delays or denials – can give TMA the ammunition it needs to fight this problem.
Nothing moves elected officials to action like a slew of real, serious complaints from constituents. As the 2021 Texas Legislature gets under way, TMA plans to collect and publicize prior authorization nightmare stories. We’ll “prime the pump” with stories physicians like you provide and use them to solicit more from the public directly.
Please submit your stories via TMA’s secure email portal. Before submitting your story to us, it is important for you to ensure that your story submission complies with state and federal laws, including, to the extent applicable, the HIPAA privacy rule. HIPAA’s safe harbor list of 18 de-identification requirements, in accordance with Code of Federal Regulations, is available here.
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