Tag: Texas Medical Association (TMA)

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Texas Insurance Commissioner Kent Sullivan is reminding insurers of their obligations under the state’s new baseball-style arbitration law to resolve disputes on many out-of-network medical bills.

In a letter Tuesday addressed to “the health plans of Texas,” Mr. Sullivan said the Texas Department of Insurance (TDI) will monitor how health plans implement Senate Bill 1264, passed during last year’s session of the Texas Legislature and now in effect.

“We expect you to be proactive to meet both the letter and spirit of SB 1264,” Mr. Sullivan said. “Review your policies and procedures and address potential issues quickly.”

The letter highlighted several of the plans’ responsibilities in relation to the law. The commissioner’s letter noted that:

• State law requires plans to cover medical screenings necessary to rule out the presence of an emergency condition;
• For emergency care, claim denials based on failure to meet the prudent-layperson standard must be based on the patient’s presenting symptoms, not on the later diagnosis code;
• Plans must meet required deadlines to promptly adjudicate clean claims; and
• Plans must be ready to provide accurate information about the new law, including required notices about mediation and arbitration, on explanations of benefits. The plans must be able to quickly respond to questions from policyholders and practitioners.

Mr. Sullivan’s letter noted that TDI has set up an SB 1264 page on its website, which includes a link to the state’s new portal for mediation and arbitration requests.

The Texas Medical Association has published a brief overview of the new law for physicians.

Last Updated On

January 09, 2020

Joey Berlin

FROM TEXAS MEDICAL ASSOCIATION

Arbitrary. Confusing. Frustrating. Never-ending. Maddening. Those are some of the terms we can actually print that describe physicians’ perceptions of insurance companies’ prior authorization requirements and approval processes. 

According to a recent American Medical Association survey, 86% of American physicians rated the prior authorization burden in their practices as “high” or “extremely high,” and 50% said that burden has “increased significantly” in the past five years. 

But this is more than a doctor’s office hassle. Patients are paying the price with their health. 

In that same survey, 91% of physicians said the prior authorization process has a somewhat or significantly negative impact on their patients’ clinical outcomes; 75% said wading through the delays, denials, and appeals leads to patients abandoning their recommended course of treatment; and 28% reported that the prior authorization intrusion led to a serious adverse event for a patient under their care. 

Your personal stories of patient harm due to prior authorization request delays or denials can give the Texas Medical Association the ammunition it needs to fight this problem. 

TMA made some progress with the passage of Senate Bill 1742 this year. That new law requires state-regulated health plans to post any prior authorization requirements on the internet and opens the door for utilization reviews to be conducted earlier in the appeal process by a physician in the same or similar specialty as the physician requesting treatment approval. 

“Senate Bill 1742 will shine a bright light into the shadowy world where insurance companies grant or deny prior approvals,” said TMA President David C. Fleeger, MD. “But we need to do more to help physicians make sure that our patients get the medicines, tests, and treatments that they need, when they need it.” 

That’s where you come in. Nothing moves elected officials to action like a slew of real, serious complaints from constituents. In the run-up to the 2020 elections and the 2021 Texas Legislature, TMA plans to collect and publicize patients’ 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. 

“We want to build enough momentum that lawmakers have no choice but to pass comprehensive prior authorization reforms,” Dr. Fleeger said. 

Please submit your stories via TMA’s secure email portal. It is important 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. We won’t use or publicize your stories without reaching out to you first.