Texas stakeholders disagree on prior authorization rules

While the Texas Medical Association (TMA) believes prior authorizations (PAs) can be an impediment to timely, quality care, groups like the Texas Association of Health Plans (TAHP) believe they exist to protect patients against fraud and to keep valuable services from being misused. A bill on this contested topic, sponsored by Rep. Julie Johnson, is currently making its way through the Texas Legislature.


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House Bill 410 would prohibit health plans from requiring PAs for certain mandated benefits. These include bone mass management, mammographies and diabetes equipment.

Debra Patt, an oncologist, spoke on behalf of TMA in support of the bill:

“When a health care plan requires prior authorization for a health care service, it requires physicians to submit paperwork before performing the service so the health plan can review the medical necessity and the appropriateness of the proposed service. A plan’s payment is then conditioned on the approval of the request. It is burdensome and can be a major impediment to optimal care.”

Patt said she knows a breast cancer reconstructive surgeon who spends $150,000 per year on PA costs alone.

“While that is an administrative burden, and that cost drives the cost of health care, the most important problem is really the patient. The patient who has breast cancer and requires a surgery, reconstruction or screening mammography — which is a necessity to have covered — has to wait and go through the prior authorization process, introducing the anxiety and challenges of them getting appropriate health care.”

She cited two polls conducted by TMA that revealed 91% of physicians reported delays in patient care resulting from PAs and 75% of physicians claimed PAs might lead to an abandonment of treatment. Furthermore, 40% of patients are forced to pay out-of-pocket for PA costs while 15% go without care entirely.

Jamie Dudensing, CEO of TAHP, testified in opposition on behalf of Texas health plans. According to her, PAs provide essential patient protections and deter fraud and abuse. She said less than 25% of medical services in Texas require PAs and that the PA process is only allowed to last up to 3 days in the state.

“Texas already has some of the strongest patient protections around prior authorizations in the country, including the fact that any PA can be appealed to an independent physician that does not work for the health plan … [patients would] always be able to go to an independent doctor to help make that decision, ensuring that no patient ever falls through the gaps of care.”

Dudensing emphasized that PAs must be evidence-based, which she says justifies their use for certain mandated benefits of health plans, such as breast reconstruction surgery. She said services like these should only be covered for patients whose health depends on them — in this case, individuals with breast cancer — and not for individuals pursuing the service for other reasons. This would be “inappropriate coverage” and would increase the cost of coverage.

To address complaints of excessive paperwork, Dudensing recommended replacing paper with electronics in the PA process.

“To just eliminate prior authorizations — not create patient safety protections, not do things that create guidelines, just to flat out, broadly eliminate them —  undermines important patient protections that prior authorizations provide, and completely eliminates that check on fraud waste and abuse … Fraud, waste and abuse in the commercial market is 50% worse than it is in Medicaid.”

Texas Employers for Insurance Reform and the Texas Association of Benefit Administrators oppose the bill for similar reasons.

The House Insurance Committee left House Bill 410 pending in committee on Tuesday.