Texas physician 'gold card' rules take effect Oct. 1

Physicians and providers in Texas will begin seeing the effects of the state's "gold card" law Oct. 1. 

Under the law, physicians who have a 90 percent prior authorization approval rate over a six-month period on certain services are exempt from prior authorization requirements for those services. 

Although the gold card bill went into effect in September 2021, the rulemaking for the law was only recently completed, Texas Medical Association Vice President of Public Affairs and chief lobbyist Clayon Stewart told Becker's

Mr. Stewart said the rulemaking process took longer than expected, adding that the uniqueness of the law may have been a contributor.

"This hasn't been done in another state, so there was really nothing to look at … what had worked in the rules, what hadn't worked in the rules," he said. "So I think it took the [Texas] Department of Insurance longer because there was not anything to model it after." 

Gold cards are granted per plan, per procedure, Mr. Stewart said. Providers and physicians do not apply for the cards. Rather, health plans run an evaluation to see if the providers meet the 90 percent threshold, and the plans are responsible for notifying the provider of whether they qualify.

Plans are analyzing approval rates for at least five prior authorization requests submitted by a provider between Jan. 1 and June 30, according to a Sept. 14 UnitedHealthcare news release. The payer said providers will get gold card notices in late September. After each six-month review period, new providers or new services for existing providers are added or removed based on the results. 

The law applies to Texas in-network physicians and providers serving fully insured, commercial business in the individual, small and large group markets, according to the release. 

One of the aims of the law is to reduce the administrative burden on physicians. 

"We found out through a national [American Medical Association] prior authorization survey that physicians were spending about 16 hours a week on prior authorizations at their practice — so two business days essentially — which is kind of ridiculous," Mr. Stewart said. "That takes them away from seeing patients when they have to be on the phone for prior authorization." 

Mr. Stewart said the Texas Medical Association is excited to see how the gold card process works. 

"Because if it doesn't function the way it needs to, we need to re-evaluate it and make sure that the process is helping prevent delays in patient care," he said. 

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