Last year, Texas passed a law, HB 3459, also known as the gold card bill. Many people in the medical industry considered this bill for both the medical industry and patients alike, and this post will explain why. We’ll cover what the bill says, why people like the bill, and why some have criticisms of it.
What Is The Bill?
To understand what the bill entails, you first need to know what a gold card is. Prior authorization is when an insurance provider determines that a medical need recommended by a doctor is necessary. If a doctor has a high rate of prior authorization decisions, they can receive a gold card. This card enables a doctor and patient not to have to deal with prior authorization.
Under House Bill 3459, a physician who has had 90% or higher prior authorizations will be able to earn a gold card. In addition, this gold card is continuous, meaning a doctor does not have to obtain it each year.
However, a gold card can be rescinded if a doctor has not kept its 90% rate. Insurers can review the physician twice a year to see if the rating remains above the required rate.
If a physician has their gold card rescinded, they have 30 days to appeal that decision. When a physician appeals the decision, they can make their case and send it to an independent review organization. This organization acts as an intermediary, providing an unbiased opinion.
If the independent review organization sides with the physician, they have their card reinstated. If not, the revoking will occur five days after the independent review organization decides.
The reviewing process also requires the person reviewing to be a Texas-licensed doctor in a similar field as the physician who has requested this service.
As a physician, it is vital that you look into this bill yourself, either through a law expert or by reading the bill itself, to understand it better. You can see if you qualify for it and determine if it’s right for you.
Why Many Like This Bill
Many physicians in Texas have commented on the bill, and they have positive things to say about it. They mainly believe the bill can help expedite medical care for patients and allow physicians to avoid trouble with insurance companies.
For the patient, getting approved is vital. A patient needs medical care right now, and the prior authorization process can be a difficult hurdle to jump over. Furthermore, even if they have a case, many insurance companies can challenge their claims, meaning that their treatment is delayed.
Seeking help from a doctor with a gold card tells the patient two things. First, the doctor has a reputation for being helpful. When a patient chooses them, they can help the patient access life-saving healthcare as soon as possible.
Second, it simply makes the approval process quicker.
On the physician side of things, it means more patients and less hassle dealing with the insurance companies. For the patient, it means more treatment.
It’s simple to understand why some people like the bill, but it also has its critics. So let’s look at why people are skeptical of this bill.
Criticisms Of The Bill
Even though the bill has praise, it’s also faced criticism, mainly at the hands of insurers.
Some insurers argue that without prior authorization, it can lead to companies approving medical treatments that might be expensive or inappropriate for the patient’s condition. Despite the doctor having an over 90% approval rating, they argue that it’s still possible for the patient to prescribe something that would typically not be approved.
Another criticism comes from physicians, who say the bill will not stop insurance companies from fighting with them. Instead, it will lead to insurance companies finding new ways to move the goalposts and deny treatments.
As you can see, most of the criticisms come from insurance companies or physicians who are skeptical that insurance companies will follow the bill. However, for doctors and patients, it’s considered a win for the most part.
As the bill has passed under a year ago, only time will tell of its impact. However, many physicians are enthusiastic about it, saying that it can be a win for patients. The hope is that other states will adopt the rule if it works as well.
Another Step Towards Automation
One could argue that this bill is yet another step toward automating the medical industry. But unfortunately, the industry is filled with paperwork, lengthy approval processes, and other hassles that make it difficult for patients to receive their treatment.
Having a doctor who’s proven receiving a gold card can make insurance approvals less troublesome for the patient and allow them to receive their care much faster. So while there are critics, most are in favor of this bill.
While the human element is always needed, there are tedious processes that one can argue should be approved by AI. A doctor who has a consistent approval rate might be one of those. Only time will tell if this is a good step in the right direction for automation, but we believe it is.
We Can Help You Automate Your Business
While this bill is a valuable tool for automation, your business still needs to have a variety of ways to make the process smooth for the patient and attract new patients.
Infinx can simplify the process by adding AI and hybrid solutions to your business to benefit everyone involved. We are dedicated to creating a medical system where everyone wins and where you can get new patients without stressing.
For more information, do not hesitate to reach out to us or schedule a demo of our prior authorization solution. Also, feel free to tell us what you think about the bill. Do you like what it says, or do you have some concerns? Of course, everyone’s answer is different, so let us know. After all, we love a healthy discussion.
