A new Texas law could have major implications for how healthcare is administered around the country. Instead of waiting for insurance companies to approve necessary tests and treatments, providers will be able to request these services right away, so their patients can get the care they need as fast as possible.
If you’re tired of waiting for insurance companies to sign off on every little thing you do, the new law should help move things along.
What Are “Gold Cards” and How Do They Work?
Providers often need approval from state-regulated health insurers and health maintenance organizations (HMOs) before administering certain types of care. The approval process can take several days, if not weeks, which delays life-saving care. This gives insurers and HMOs the power to dictate whether they want to pay for the services the doctor has requested.
Texas lawmakers recently gave the green light to House Bill 3459, which is expected to take effect on September 1st. The bill aims to cut down on the approval process for medical treatments.
The Texas Medical Association was a major proponent of the bill. TMA focused on getting rid of onerous red tape in the medical industry throughout the legislative session. The new law allows physicians to obtain a “gold card” exemption from certain health plans’ prior authorization review requirements when administering certain treatments and tests.
Doctors will receive a gold card based on how often they receive approval from insurers and HMOs. Under the new law, physicians will be eligible if their prior requests for certain treatments were approved by insurers and HMOs 90% of the time within a six-month review.
According to TMA, around eight out of ten physicians said they often have to wait for final approval from the insurance companies when treating their patients. Of those, 85% said that the process delays patient care anywhere from days to months.
Dr. Patt, an oncologist who regularly seeks approval when treating breast cancer patients, says these delays can make or break a patient’s chances of survival.
“It interrupts the care of patients moving forward, and delays appropriate care,” she said. “Whenever I order things like imaging, it’s to evaluate response to chemotherapy, usually in patients with advanced cancer. [Waiting for authorization] can delay appropriate care decisions, sometimes by a month or more – which can have a significant impact on the care of those patients.”
“That can change a child with a urinary tract infection from a local problem to a septic illness that could be potentially life-threatening,” she said.
“If I order things like a CAT scan to evaluate my patient’s breast cancer to make sure it hasn’t spread somewhere else, frequently, I have to go through an insurance company to make sure that they think that’s okay,” Patt added. “You can imagine patients tremendous anxiety with their new cancer diagnosis if they have to wait a week or two to get information that they can get appropriate scans.”
The Future of Authorization
Insurers and HMOs began the prior authorization approval process years ago to prevent providers from ordering medically unnecessary tests and treatment, especially when treating complex or chronic conditions. However, the process has exploded in recent years. Today, many providers rely on the approval process when administering basic or routine care.
Dr. Patt, whose record satisfies the 90% approval threshold, says she’s looking forward to treating and testing her patients faster, now that she no longer has to worry about the approval process. “The prior authorization burden is real,” she added.
However, health insurers say the new law doesn’t give them enough time to decide whether a physician should have the final say over treatment.
Alicia Pierce, director of communications for the Texas Association of Health Plans, said, “The way that it’s implemented, having just this very basic sampling, and a limited window of time, we can’t have a good assessment if physicians are really prescribing care and treatment in good faith. And it’s just an invitation for waste, fraud and abuse.”
Pierce says issuing gold cards is a mistake. She argues there are better ways to speed up the approval process, such as banning fax machines and making it easier to respond to and fix clerical mistakes. She says if a patient is taking prescriptions from more than one provider, insurance companies are often the only ones making sure the combination won’t lead to a bad reaction or potential side effects.
“You have multiple providers who are providing different drugs and different prescriptions that may not show up for the doctor. And insurance companies are the only ones that have that 360 view of the patient’s health care,” Pierce said.
But Dr. Patt sees it differently. She says insurance companies are just trying to cut down on costs. “They’re not in patient rooms, giving care to patients every day,” Dr. Patt said.
If the gold card law is touted as a success, we could see similar legislation being introduced across the country.