Insurance

Prior Authorization Fuels Physician Burnout, Decreases Access to Care, AMA Survey Finds - 04/03/2025

Prior authorization continues to intensify physician burnout, increase health care costs, and limit patients’ access to care, per AMA. Meanwhile, TMA advocates against health plans’ use of artificial intelligence in the prior auth process and aims to reduce its burden on physicians.   

Panel Makes Big Change in Draft Federal Surprise Billing Law - 03/18/2025

Thanks to incessant lobbying from physicians, hospitals, organized medicine, and the Physicians Advocacy Institute, a key congressional committee today made significant revisions in a bill to reduce the strain of surprise billing on patients. “This certainly sounds like an improvement,” said Texas Medical Association President David Fleeger, MD, “but the devil will be in the details.”

BCBSTX Reprocessing Flu Testing Claims Following Incorrect Denials - 03/03/2025

Blue Cross and Blue Shield of Texas (BCBSTX) is reprocessing certain claims filed between Jan. 1 and Feb. 13, the payer told TMA’s Physician Payment Resource Center. Physicians should continue to review claims to ensure they are correctly reprocessed.

TDI Eases Prior Authorization Request Process for Prescription Renewals - 02/28/2025

After a three-year effort, the Texas Medical Association recently secured a form change that allows physicians to bypass the most onerous part of prior authorization requests when renewing an existing prescription.

TMA Seeks Prior Authorization Reform This Legislative Session - 02/13/2025

The Texas Medical Association (TMA) seeks to cut health insurers’ burdensome delays and denials of patients’ care this legislative session.

Aetna Reverses NPP Payment Reduction Under Incident-To Billing - 02/12/2025

Aetna previously intended to pay nonphysician practitioners (NPPs) 85% of the allowable amount, regardless of whether they billed directly or “incident-to” a physician’s diagnosis and treatment. Meanwhile, the payer upholds a new credentialing requirement.

More Than One in Five Claims Denied in Texas by Non-Group Qualified Health Plans - 02/11/2025

A study of health plans available through HealthCare.gov in 2023 shows one in five claims nationwide were denied – with Texas ranking among the top five states for in-network denials.

Landmark Antitrust Settlement in BCBS Case Granted Preliminary Approval - 01/09/2025

Physicians can now file a claim in a $2.8 billion settlement fund given preliminary approval by a U.S. District Court involving Blue Cross Blue Shield. The final verdict is expected in July.

Putting the AI in Paid: Payer Use of Artificial Intelligence Sparks Physician Concerns - 12/20/2024

Physicians - worried about payers' increasing use of artificial intelligence to process prior authorization requests, enable value-based care models, and systematically deny coverage - are seeking transparency on behalf of their patients and practices.

Protect Patients From Inadequate, Narrow Networks - 11/18/2024

In an out-of-network surprise billing situation, the patient and the insurer have a contractual agreement. The physician and insurer do not. As a result, when we remove the patient from the claims settlement process, the insurer has little market accountability unless additional statutory protections are created.

TMA Leery of Proposed Balance Billing Law - 11/18/2024

The Texas Medical Association is deeply skeptical of a state senator’s freshly filed effort to prevent physicians from balance billing patients for the services they provide. On Thursday, Sen. Kelly Hancock (R-North Richland Hills) filed Senate Bill 1264, a measure to address surprise out-of-network medical bills. The legislation emerged with no input from the House of Medicine

Patient Care Protected: Prior Authorization Reforms - 11/18/2024

Carrying the torch from last session, the Texas Medical Association followed up on its 2021 gold-card success with a new prior authorization reform for vulnerable patients and other insurance-related policy wins this session.

“Gold Card” Cleanup, Network Adequacy Bills Head to House - 11/18/2024

Building on years of Texas Medical Association advocacy, two House committees cleared a pair of bills that would strengthen existing state laws and regulations by further easing health plans’ onerous prior authorization requirements and strengthening network adequacy protections.

TMA Joins New Statewide Insurance Reform Coalition - 11/08/2024

The newly created Texas Coalition for Patients calls for “common sense policy reforms” around health insurance, including greater transparency around prior authorizations. TMA leaders say the organization will augment medicine’s related advocacy.

United Launches National ‘Gold Card’ Program - 09/17/2024

UnitedHealthcare announced the launch of what it’s calling a national “gold card” program, which purports to allow physicians to bypass the prior authorization process and is set to begin Oct. 1.

BCBSTX to Require E/M Codes for Consultation Services - 09/03/2024

Starting Nov. 18, Blue Cross and Blue Shield of Texas will no longer pay physicians for outpatient or inpatient consultations when they report those services with Current Procedural Terminology codes 99242 – 99245 and 99252 – 99255.

Aetna to Correct G2211 Payment Disparities - 08/28/2024

Aetna will correct erroneously low payments made to physicians for G2211 claims following Texas Medical Association advocacy during a meeting with the payer Aug. 2.

TMA Applauds Appeals Court’s Ruling in Physicians’, Patients’ Favor - 08/06/2024

Statement by G. Ray Callas, MD, TMA president, in response to the U.S Court of Appeals for the Fifth Circuit’s ruling Friday in TMA’s favor. The court affirmed the district court’s decision in an appeal filed by several federal government agencies to TMA’s earlier victory in a lawsuit challenging certain components of the federal agencies’ final rules governing independent dispute resolution for surprise medical bills under the No Surprises Act. TMA argued the case in December 2022 in the U.S. District Court for the Eastern District of Texas. The district court later ruled in TMA’s favor, prompting the federal government appeal.

UHC Expands EZ Claim Pay Service to Certain Texas Medicare Patients - 07/26/2024

As of July 1, UnitedHealthcare has expanded its EZ Claim Pay service to Texas for Medicare Supplement Plan G patients, and for those patients who enroll, physicians won’t need to bill them directly for their Medicare Part B deductible.

G-Code Payment Frustration Persists With Inconsistent Implementation - 06/25/2024

Deepening ongoing physician concerns over Medicare’s add-on code for complex care, two major payers have either reduced payment for G2211 claims or announced plans to stop paying certain claims associated with the code altogether. Read more.

UHC Postpones Higher Liability Coverage Requirements Plan - 06/20/2024

UnitedHealthCare (UHC) postponed a plan that would require Texas physicians to substantially increase their professional liability insurance coverage in order to participate in its networks. The move comes after the Harris County Medical Society and Texas Medical Association expressed serious concerns about the new policy.

TDI Debuts Network Adequacy Waiver Hearings - 05/24/2024

Physicians soon may hear from the Texas Department of Insurance (TDI) regarding public hearings for health plans seeking a network adequacy waiver. The hearings are required under a new state law championed by TMA to address inadequate networks and an overused waiver process. Read more.

New Medicare Advantage Rules Aim to Improve Access, Equity - 05/15/2024

 Medicare Advantage enrollees soon may benefit from expanded access to outpatient behavioral health care and more equitable prior authorization policies.  

New Federal Rules Limit Short-Term Insurance Plans, Enhance Protections - 04/17/2024

Following advocacy by the Texas Medical Association, the U.S. departments of Health and Human Services, Labor, and the Treasury recently issued final rules that strengthen consumer protections related to short term, limited duration insurance.

TMA Pushes for Prior Authorization Limits, Clarity - 04/16/2024

After hearing story after story of delays and denials, the Texas Medical Association is pushing the Texas Legislature to sign off on measures that would significantly curb insurers’ ability to require prior authorization on needed care, as well as clarify for both physicians and patients what it means when prior authorization is required.