Texas Prior Authorization Law Ignites Accountability Debate

To health insurers, a new Texas law that significantly limits prior authorization practices will effectively eliminate health care providers’ accountability to offer safe, high-quality and cost-effective care. To Texas providers, the measure is a long-awaited first step toward having clinicians spend less time on arduous paperwork and more time on patient care.

Industry observers say both sides have valid arguments, but they also worry that Texas’ legislation may be so difficult to implement that even its best intentions could fall flat.

House Bill 3459 — which Republican Gov. Greg Abbott signed into law in June — allows physicians who have had PA requests for prescriptions and treatments approved by a private insurer 90% of the time in the most recent six-month review period to receive a “gold card” PA exemption from the insurer for the applicable prescription/treatment. That requirement will go into effect on Jan. 1, 2022, but starting Sept. 1, 2021, health plans must use Texas-licensed physicians of the same or similar specialty as a treating physician when conducting peer-to-peer review calls with doctors seeking prior authorization.

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Leslie Small

Leslie Small

Leslie has been working in journalism since 2009 and reporting on the health care industry since 2014. She has covered the many ups and downs of the Affordable Care Act exchanges, the failed health insurer mega-mergers, and hundreds of other storylines spanning subjects such as Medicaid managed care, Medicare Advantage, employer-sponsored insurance, and prescription drug coverage. As the managing editor of Health Plan Weekly and Radar on Drug Benefits, she writes and edits for both publications while overseeing a small team of reporters who also focus on the managed care sector. Before joining AIS Health, she was a senior editor for the e-newsletter Fierce Health Payer, and she started her career as a copy editor at multiple local newspapers. She graduated with a dual degree in journalism and political science from Penn State University.

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