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For your staff


Beginning Sept. 1, physicians can use a single, uniform, paper prior authorization form for medical and health care services and a simi- lar standardized form for prescription drug benefits. Texas Depart- ment of Insurance (TDI) oficials say health plans may start accepting the forms before then. The agency posted


a copy of the medical and health care services form and its instruction sheet, which can be found at tma.tips /priorauth. You may also request the documents by mail from Texas De- partment of Insurance, Rate and Form Review Ofice, Mail Code 106-1E, PO Box 149104, Austin, TX 78714-9104. TDI expects to


release the prescription drug form by March. The forms must be reproduced without changes.


commercial insurance plans the prac- tice accepts. That’s after researching patients’ individual health plans and formularies and whether preautho- rization is needed in the first place. And that doesn’t include the handful of additional forms she may fill out for services like home health care. Some practices dedicate one em-


ployee to do nothing but prior autho- rizations. As a solo physician practice, however, Austin Internal Medicine Clinic cannot afford that luxury. “I’m it,” said Sharon Blancarte, Dr. Blancarte’s wife and office adminis- trator. Nor is it unusual for patients to


experience delays in getting their pre- scriptions because she has to go back and forth with both the insurance company and its pharmacy benefit manager — and Dr. Blancarte — to fill out separate forms for each entity. For the most part, insurers ask for similar information. “But it’s like going to check out for


groceries, and every single credit card machine is different, and they ask you different questions in different order,” Ms. Blancarte says. “It takes me time to do it. You have to have just the right information. And if I have patients waiting, I can’t be stuck on the phone. It would be so much easier on us if everyone asked the same thing. And it means patients get their prescriptions sooner rather than having to wait.”


MAKING LIFE EASIER Thanks to two of the Texas Medical Association’s 2013 legislative victories, the day has arrived when physicians no longer have to deal with hundreds of different prior authorization forms from multiple payers. Beginning Sept. 1, physicians can


use a single, uniform, paper prior au- thorization form for prescription drug benefits and a similar standardized form for medical and health care ser- vices. TDI and health plans must make the forms available in paper form and electronically on their websites. At press time in January, TDI post-


30 TEXAS MEDICINE March 2015


ed a copy of the medical services prior authorization form, which can be found at tma.tips/priorauth. (Also see


“For Your Staff,” at left.) Public com- ment regarding the prescription drug prior authorization form was still un- der way, and the department expected to release it by March. TMA physician leaders and lobby


staff worked hard to pass Senate bills 644 and 1216 in 2013. They required TDI to appoint workgroups that in- cluded physicians, hospitals, pharma- cies, health plans, and others to design the forms for use across public and private payers in Texas, including:


• Commercial carriers, • HMOs, • Medicaid and Medicaid managed care organizations,


• The Children’s Health Insurance Program (CHIP), and


• Plans covering employees of the state of Texas, most school districts, and The University of Texas and Texas A&M University systems.


Medicare, the state Workers’ Com- pensation program, and self-funded employer plans are excluded. TMA research shows that a single


health plan could have dozens of pre- certification forms for various proce- dures and drugs, and these and other administrative interactions with in- surers cost an average of $80,000 per physician per year. The laws do not require physicians


to use the standardized forms, but for those choosing to do so, health plans must accept them as valid prior autho- rization requests. Bruce Levy, MD, is chief executive


officer of Austin Gastroenterology PA and a former executive director for the Texas Medical Board who serves on the workgroup that developed the medical and health care services prior authorization form. “Our No. 1 goal was to create a sin-


gle-page form that could be used in- terchangeably for every third-party payer,” he said. “Just like we have a


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