Texas lawmakers recently introduced several bills that would address the health plans’ unnecessary delays that are resulting in delays for patients.
The Texas Orthopaedic Association strongly supports the bills that have been introduced by Sen. Dawn Buckingham, MD, Rep. Greg Bonnen, MD, Rep. Julie Johnson, and Rep. Sarah Davis.
Make the prior authorization process easier for patients and physicians. HB 2327 and SB 1186 would require HMOs to provide details to patients and physicians about what factors are used to determine a prior authorization formula. In addition, physicians who routinely have their prior authorizations approved would be exempt from further prior authorizations under a process that is set up by TDI.
Promote greater patient choice. Some health plans have dropped physicians from their networks for referring patients to out-of-network providers. In some cases, the most appropriate provider for that service may have no choice but to be out of network. HB 2367 would prohibit health plans that engage in this practice from bidding on state contracts.
Ensure that health plan reviewers have expertise regarding the reviewed service. HB 2387 and SB 1187 would require health plans to use a physician of a similar specialty for utilization reviews regarding a particular service.
Ensure that patients have accurate network directories. HB 1880 and SB 1188 would require health plans to update their network directories every two days. In addition, TDI would be required to perform network adequacy examinations at least every two years for PPO products.
Give patients information about their physicians’ network status and expected financial liability. HB 2520 would require health plans to tell the patient ahead of time about the network status of the physicians and the patient’s expected financial liability for an approved prior authorization.
Prohibit prior authorization for mandated benefits. HB 2408 would prohibit prior authorizations for state-mandated services, such as osteoporosis prevention.