Becker's Spine Review

59 HEALTHCARE NEWS Why some payers, physicians are voicing their opposition to the Texas physician 'gold card' By Alan Condon A new law that took effect Sept. 1 in Texas aims to ease the administrative burdens that insurance companies place on physicians, but some payers have voiced their opposition to the legislation, claiming it will put more patients at risk. Under the legislation, physicians in Texas who are approved 90 percent of the time for certain procedures, treatments or drugs will receive "gold card" status and will no longer require prior authorization from insurers. e idea is that top-performing physicians will be able to bypass the approval process for certain services, eliminating a significant administrative burden, and thus spend more time with patients. e legislation, written by state Sen. Greg Bonnen, MD, R-League City, a spinal neuro- surgeon with Houston Physicians' Hospital, has received support from several Texas phy- sician societies and could prove beneficial for providers, as many insurers require prior au- thorization for various imaging, medications and procedures. Payers opposing the gold card, including Cigna, Blue Cross Blue Shield of Texas and Superior HealthPlan, claim that it will put pa- tients at risk, arguing that prior authorization is necessary to minimize costly procedures and act as a check on potentially unnecessary, inappropriate or unsafe medical treatments. "A lot of time what goes on with patient safe- ty isn't really just what happens with one physician," Jamie Dudensing, CEO of Texas Association of Health Plans, told Houston Public Media. "Health plans tend to be one of the few entities watching a patient's role in healthcare where you have a 360-degree view of what's happening." Some physicians don't see the legislation as streamlining the care delivery process and expect insurers to find another way of mov- ing the goal posts. "In my opinion, the insurance industry will simply enunciate a new series of excuses and provide new hoops and hurdles for the practi- tioner's office to deal with," Robert A. Peinert Jr. MD, a retired Harlingen, Texas-based or- thopedic surgeon, told Becker's. "When profit for the insurance industry is the main goal of the industry, I expect they will focus on maxi- mizing profit, and the best way to create profit in health insurance is to decrease utilization of expensive tests, procedures and surgeries. "e best way to do that is to create a sta- tistical analysis of all tests, procedures and surgeries and declare that their propriety sta- tistics prove that certain expensive tests, pro- cedures and surgeries do not provide either enough diagnostic information or do not re- sult in sufficiently meaningful life or function improvements so as to justify payment. In other words, there are many ways to deprive patients of care." Despite some opposition, insurers in Texas have begun analyzing which physicians qual- ify for "gold card" status, but some provisions in the law may be too challenging for insurers to implement, according to Ms. Dudensing, which could lead to prior authorization being eliminated across the state, not just for a veri- fied group of physicians. But many physicians are hopeful of the changes the physician gold card may bring, and success in Texas could lead to other states adopting similar laws. n UnitedHealthcare, Anthem behind on billions in payments to hospitals By Nick Moran T he country's two largest insurers — UnitedHealthcare and Anthem — are behind on billions of dollars of pay- ments to hospitals due to new reimbursement rules, claims issues and retroactive claims denials, according to a Kaiser Health News article republished in USA Today. For instance, Richmond-based Virginia Commonwealth University Health alleged Anthem owes the provider $385 million, according to the Oct. 5 article. More than 40 per- cent of payments are more than 90 days old, violating state law dictating that insurers must pay claims within 40 days. The American Hospital Association told reporters that complaints span the country. Between June 30, 2019, and June 30, 2021, Anthem's unpaid claims rose from 43 per- cent to 53 percent, accounting for $2.5 billion. UnitedHealth's unpaid claims have remained at 54 percent over the past two years, according to the report. Anthem delays payments through new paperwork, require- ments for prior authorization or requests to speak with phy- sicians directly, according to the report. It also creates hur- dles that encourage patients to use facilities it owns. Anthem said many of these steps are taken to control ex- cessive prices from hospitals. Patients complained that UnitedHealthcare denied pay- ments due to a lack of documentation of medical necessi- ty or delayed payments due to prior authorization system downage, according to the report. The insurer told reporters that facilities may appeal claims decisions and that the July prior authorization downage was "resolved quickly." n

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