The Texas Legislature Passed the Nation’s Model Prior Authorization Law

HB 3459, which passed in May 2021, will:

• Prohibit a PPO or HMO regulated by the state of Texas from requiring a prior authorization for a physician who meets certain thresholds.
• If during a prior six-month period a physician was approved for at least 90 percent of prior authorizations for a particular service, that physician will not be subject to prior authorizations for that service for the next six months.
• Once the six-month period ends, the health plan may rescind the physician’s exemption if it is documented that the physician did not meet certain medical criteria. The physician would have the opportunity to repeal the decision through an independent process.

Data gathered by TSAOG Orthopaedics in San Antonio demonstrates the prior authorization burden on patients, physicians and health plans.