Soon, physicians who’ve had their fill of insurers’ burdensome prior authorizations will have the chance to earn their way out of them.
The Texas Medical Association wants to make sure the new law giving doctors that “golden” opportunity will be implemented as intended – and is pushing back against health plans’ attempts to reduce its impact.
TMA submitted a pair of detailed written responses to a Texas Department of Insurance (TDI) request for information on House Bill 3459 by Rep. Greg Bonnen, MD (R-Friendswood), which passed in this year’s regular session of the Texas Legislature. Under HB 3459, for certain health plans, physicians can earn a continuous exemption from prior authorization – or “gold card” – by earning approvals on at least 90% of their preauthorizations on a given service over a six-month period.
The law applies to preauthorization requests made from Jan. 1, 2022, onward, although TDI is still determining how to implement that effective date.
Like all laws, putting the gold-card bill in practice requires regulatory nitty-gritty. So the TDI request for information, which came ahead of a Sept. 23 stakeholder meeting on HB 3459, asked for comments and responses to questions the agency had surrounding the law.
TMA’s recommendations – while referencing and often refuting comments from health plan advocacy groups – clarified pieces of the law and offered insights on how to move forward with rulemaking.
For instance, TDI requested an example of how insurers should evaluate a physician for a gold card exemption if there are less than five claims for a particular service over the most recent six-month period. That request appeared to assume the law requires evaluation of at least five claims for an insurer to issue the initial gold card. But citing the law itself, TMA said if the physician submitted four or fewer claims for a service over a six-month period, the 90% success-rate threshold to earn a gold card would still apply.
“For example, if a physician had four claims and all were approved for that particular service, the physician would receive a preauthorization exemption for that service from the HMO or insurer, because the physician would have a 100% approval rate for those claims,” TMA wrote.
Although the gold card will be continuous after it’s initially granted, health plans will have the opportunity to reevaluate a physician’s exemption status at six-month intervals. Insurers must notify the physician at least 25 days before a rescission would take effect, with the physician getting a chance to appeal to an independent review organization.
TMA argued that for an insurer to rescind a physician’s gold card (rather than issue it in the first place), the insurer’s retrospective evaluation of claims for medical necessity must include at least five claims.
TMA’s other points in its two rounds of responses to TDI included:
Through rulemaking, the agency should impose “express requirements” on health plans to provide gold-card denial notices, along with information on how to appeal; and
When an insurer conducts a retrospective review of between five and 20 claims to determine whether it will rescind a gold card, the insurer should be required to “review the maximum amount of claims available within that range. For example, if only five claims have been submitted during the relevant period for the particular service, that would be sufficient for the determination. If 20 or more claims have been submitted for the particular service during the relevant evaluation period, then the issuer should be required to review 20 claims prior to making the determination.”
Among a large number of signatories on TMA’s first round of responses to TDI were the Texas Society of Anesthesiologists, the Texas College of Emergency Physicians, and the Federation of Texas Psychiatrists.
Along with allowing for prior authorization exemptions, HB 3459 also requires that peer-to-peer calls occurring prior to a utilization review denial be conducted by a Texas-licensed physician in the same or similar specialty as the physician who requested the service.
TMA will closely monitor rulemaking on HB 3459 and provide more information on the law once TDI’s rules are final, which is expected to occur before the end of the year.