A sort of Texas lawIn some cases, prior authorization was cancelled, and the state’s health care community received mixed reviews. Although the provider claims that this pioneering law is a long-overdue measure to reduce administrative burden and increase access to care, the payer warns of potential patient harm that may ensue.
The law will come into effect on September 1st, and if the provider earns income, the law prohibits health insurance companies from requiring pre-approval of services “Gold Card” statusIf the providers all have a 90% pre-authorization approval rate, they can get this status. Health plans that require prior authorization must evaluate the provider’s eligibility for a gold exemption every six months.
“Doctors or providers do not need to apply for an exemption,” Alicia Phillips Pierce, the communications director of the Texas Health Plans Association, said in an email. “If prior authorization is required at the time of the waiver application, the health plan must immediately provide notice of the waiver and payment requirements.”
Phillips Pierce said that to cancel the gold status, the insurance company must review a random sample of 5 to 20 claims submitted by the provider during the most recent evaluation period and find that the approval rate is less than 90%. The payer can only withdraw the exemption in January or June of any given year.
The law does not apply to all health plans, only those that are under the jurisdiction of the state but are not funded by the state. These include state-regulated commercial HMO plans, preferred provider benefit plans and exclusive provider benefit plans. The Medicaid program is not subject to law.
For providers, the law provides much-needed back-office relief.
“I spend 15 hours a week managing pre-authorization on the phone, that’s when I can’t take care of patients,” said Dr. De Brapat, a cancer specialist in Austin and a former member of the Texas Medical Association Committee The chairman is in a telephone interview about legislation. “We have tripled the staffing to manage prior authorization.”
Then there is the issue of delayed patient care. Patients usually have to wait for the insurance company’s approval before starting treatment.
“When I needed to provide emergency chemotherapy, I couldn’t get the authorization for the patient in time,” Pat said. “This may be the difference between life and death.”
Pat believes that the new law will help patients get the care they need quickly. But the payer holds diametrically opposite views.
Phillips Pierce of the Texas Health Planning Association said that pre-authorization is an important tool to protect patients from overtreatment and improper or dangerous care.
“Health plans are usually the only plans that provide a 360-degree view of the patient’s treatment, and security editing can help prevent dangerous interactions with care or prescriptions provided by multiple providers,” she said.
Other criticisms of the law by the payer relate to the fact that this gold card practice has taken place, and the supplier and the payer are already working together to improve the prior authorization process.
“Gold combing plans may be targeted at specific services, and when used, the provider’s performance can be reviewed regularly to ensure consistent high-quality care and patient safety,” said Kristine Grow, senior vice president of communications for the US Health Insurance Program. Payer’s Association. “[But the new law] Distorting this concept by mandating extensive provider immunity without provider liability. “
For Pat of the Texas Medical Association, these concerns are unfounded. The provider must practise in accordance with the rules set by the state medical board. She said that if they are found to be improperly practicing, they will be sanctioned by the board of directors.
At the same time, the gold combing law that will take effect in more than a month has only scratched the surface of the reforms required by the healthcare industry.
Pat said similar policies need to be developed at the federal level to prevent prior authorization procedures from restricting care.
Photo: Piotrekswat, Getty Images
