By Ezequiel “Zeke” Silva III, MD

The Effects of Prior Authorization

By Ezequiel “Zeke” Silva III, MD

Prior authorization (PA) is intended to confirm the medical necessity and appropriateness of health care services that may be emerging, experimental or infrequently performed. The application of PA has been expanded over the past five years to now include common procedures, therapies and medications. Despite this overuse, most services subjected to PA are eventually approved by the health plans. However, approval often requires an extensive effort by physicians and their staff, regularly necessitating a peer-review process. The complaints among patients and physicians are growing and have been heard by the Texas Medical Association (TMA) and Bexar County Medical Society (BCMS).

To better understand the effects of PA, in February 2020, the TMA performed a PA physician survey. The results are telling. An astonishing 78% of physicians report that PA had led their patients to abandon their course of treatment, and 38% report that PA led to a serious adverse event, according to a TMA reference. Subsequent AMA survey data from December 2020 found that, on average, physicians and their staff spend 16 hours a week on PA, while 40% of practices employ full-time staff members who work exclusively on PA.

For these reasons and others, addressing PA was a top priority for the TMA and BCMS during Texas’ 87th regular Legislative Session. The TMA and BCMS supported several legislative PA reform bills, including bills requiring increased oversight of the health plans, greater transparency to the process and decreased burdens on physicians. BCMS members provided House and Senate testimony numerous times in support of these bills. These advocacy efforts yielded significant progress in holding the health plans accountable for the consequences of burdensome PA practices. Several of our supported bills were voted favorably out of the House Insurance Committee. Ultimately, our legislative efforts resulted in HB 3459, by Rep. Greg Bonnen, R-Friendswood, Rep. Penny Morales Shaw, D-Houston and Sen. Dawn Buckingham, RLakeway, with considerable support by Sen. Jane Nelson, R-Flower Mound, passing through both the House and Senate. The bill goes into effect on September 1, 2021.

HB 3459 requires that certain health plans provide gold carding status for frequently approved services on a physician-by-physician basis. Gold carding status would apply to a physician who performs a service and has preauthorization requests for that service approved no less than 90% of the time during the relevant six-month evaluation period. This physician would not be subject to PA requirements for that service after receiving gold card status (but the health plan may assess continued qualification for gold card status at certain intervals). HB 3459 also requires that peer-to-peer review calls be conducted by a physician of the same or similar specialty as the treating physician. Further, HB 3459 would require that any physicians conducting the peer-to-peer calls be licensed to practice medicine in the state of Texas.

The health plans’ growing use of the PA process has gone too far. Physicians spoke up, and the TMA and BCMS heard our voices loud and clear. HB 3459 will help protect our practices and our patients from the harms of excessive PA practice. Physicians should be proud of the progress we made in the 87th Legislative Session to address PA burdens.

Ezequiel "Zeke" Silva III, MD is a member of the South Texas Radiology Group and the TMA Council on Legislation. He is Chair of the AMA RVS Update Committee (the “RUC”) and is an active member of the Bexar County Medical Society.