The halls of Cordell Hull were a frenzy of activity this week as lobbyists and lawmakers hurried to file legislative proposals ahead of the weekend’s projected snow storm. While the Senate has already confirmed plans to cancel committee hearings and floor sessions next week, the House opted to delay proceedings until Wednesday. Neither chamber, however, has indicated plans to delay their respective bill filing deadlines scheduled for next Thursday and Friday.

To date, over 600 bills have already been filed with that many more expected to drop in the coming week. TMA’s government affairs team spent the week securing sponsors for the association’s priority issues this session, which include:

TENNCARE PROVIDER RATE INCREASES

Sen. Bo Watson (R-Hixson) | Rep. Ryan Williams (R-Cookeville)

TennCare reimbursement has long lagged behind Medicare and commercial rates, often falling well below the actual cost of delivering care. This persistent underpayment has led physicians and other providers to limit their services or withdraw from the TennCare program in order to keep their practice doors open. As the TennCare provider network has constricted, access to essential services has left many Tennesseans in rural communities with no option but to travel long distances to receive care, or forgo care altogether.

TMA has identified funding sources that can address these payment gaps and stabilize rural provider networks. By strategically leveraging available tax revenue and drawing down federal match dollars, TMA is working to increase TennCare’s reimbursement rates for primary care physicians, physician assistants and advance practice registered nurses to bring them closer to Medicare rates. These targeted increases will help improve patient access and promote long-term workforce recruitment and retention efforts.

ONE BIG BEAUTIFUL INSURANCE BILL (OBBIB)

Sen. Shane Reeves (R-Murfreesboro) | Rep. Sabi Kumar, MD (R-Springfield)

Despite recent progress in health insurance reform, physicians and medical practices continue to face significant administrative and payment-related challenges that interfere with their ability to operate their practice and provide high-quality care. Excessive prior authorization requirements delay necessary treatment, disrupt continuity of care and, in many cases, worsen patient outcomes. This is especially true for routine medications and services that are frequently approved and offer little to no demonstrated cost savings when subjected to prior authorization.

At the same time, a new administrative hurdle is coming into play: downcoding, or the practice of assigning a lower-level code for a service or procedure performed in order to reduce reimbursement, typically for complex, time-intensive care. This systematic underpayment of service is forcing many physicians to divert time away from patient care to dispute improperly adjudicated claims.

Through a comprehensive bill, TMA is seeking targeted updates to several health insurance statutes to ensure health plans process claims fairly, transparently and in compliance with existing state laws. Key changes of OBBIB include:

• Prior authorization (PA)
  • The bill would eliminate PA requirements for routine services and generic medications that are regularly approved, such as biosimilars, immunizations, certain gynecological procedures, outpatient mental health services, opioid use disorder treatment, pediatric hospice care, neonatal abstinence syndrome treatment, services delivered under value-based care contracts, and care for chronic conditions unless clinical criteria have changed.
  • When PA is required, the bill would require any denial to be issued by a licensed physician who must review the patient’s medical history and treating provider’s recommendations.
  • The bill also prohibits the use of separate PAs for additional services, procedures or devices if discovered when authorized care is performed (i.e. during a surgery), and requires such treatment to be reimbursed.
• Downcoding
  • Under this bill, the process of automatically downcoding would be prohibited. Claims that are downcoded would first require a review of the patient’s medical record.
  • The bill also specifies that insurance contracts and payment policies must account for a patient’s medical complexity and co-morbidities when determining reimbursement.
    
• Enforcement
  • The Tennessee Department of Commerce & Insurance would be required to perform mandatory audits of health insurance companies every three years to ensure compliance with prior authorization and prompt pay statutes.

Taken together, these reforms aim to reduce administrative burden, promote timely access to care, ensure fair reimbursement and restore the focus of the healthcare system to the physician-patient relationship.

In the coming weeks, TMA’s advocacy division will review all introduced legislation to evaluate its impact on physicians before the Legislative Committee takes positions on bills on Feb. 16. Members are encouraged to participate in the legislative process to help advance or oppose legislative proposals defined as priorities by the House of Delegates. Register for calls-to-action through our Grassroots Action Network and be sure to sign up for TMA’s annual policy briefing and lobby day in Nashville, Doctors’ Day on the Hill, taking place on Tuesday, March 3.