In Texas, Certain Docs May Bypass Prior Authorization

Starting this month, many Texas physicians, including orthopedists, will no longer have to wait on prior authorization from health insurance companies to treat patients.

Texas House Bill 3459 was passed on June 18, 2021, and officially went into effect on September 1, 2021. The bill was sponsored by the following: Texas Representative Greg Bonnen, M.D.; Texas Representative Penny Morales Shaw; and Texas Senator Dawn Buckingham, M.D.

Dr. Bonnen wrote the bill. He is a neurosurgeon with Houston Physicians’ Hospital in Webster, Texas. Dr. Bonnen specializes in spine surgery and movement disorders.

Now, certain physicians can earn a “gold card” exemption from certain prior authorization review requirements. Physicians achieve gold card status by having a track record of prior approvals from insurers or HMOs. In addition to the gold card provisions, the new law also requires that Texas specialists perform the prior authorization review. Previously, this could be done by out-of-state physicians.

Physicians in support of the legislation spoke out about unnecessary delays in patient care. A Texas Orthopaedic Association infographic calling for legislative reforms on prior authorizations stated, “For nearly 1 [one] in 5 [five] patients who sought an orthopaedic procedure or surgery through TSAOG Orthopaedics in 2020, insurance requests for additional clinical data routinely delayed a healthcare decision by one week or more.”

The Texas Medical Association, based in Austin, Texas, is the largest state medical society in the country. It represents over 55,000 physician and medical student members. According to the Texas Medical Association, “Eight in 10 Texas physicians reported having to obtain prior authorization for medical procedures and even common, generic prescriptions. Four-fifths (85%) reported prior authorizations delayed patient care, often leading to an adverse event for their patient.”

Not all groups supported the bill. Insurance companies opposed the law, claiming it puts patients at risk and is burdensome to implement. The Texas Association of Health Plans CEO Jamie Dudensing spoke out against the legislation. The Texas Association of Health Plans is the statewide trade association. It represents health insurers, Medicaid plans, Medicare Advantage plans, and other Texas health care entities.

In one interview, Dudensing commented, “A lot of time what goes on with patient safety isn’t really just what happens with one physician. Health plans tend to be one of the few entities watching a patient’s role in health care where you have a 360 degree view of what’s happening.”

Dudensing also discussed the potential costs and difficulties with implementing the legislation, stating, “The bill was constructed in such a way that makes it almost impossible to implement. So instead of implementing gold carding, it’s really likely that most plans are just going to eliminate prior authorizations.”