Insurance

BCBSTX to Implement Downcoding Policy July 1 - 05/22/2026

Payments for services provided to commercially insured patients will be lowered if the new Blue Cross and Blue Shield of Texas (BCBSTX) claims editing and review process determines those services do not support the E/M code level on the claim. TMA is ready to analyze the full policy, yet to be released.

Webinar: What Practitioners and Facilities Need to Know About Navigating the MultiPlan Litigation - 05/21/2026

TMA has joined the federal litigation alleging MultiPlan and major health insurers colluded to suppress out-of-network reimbursement rates. On June 23, learn what this case means and key legal developments and strategies for affected physicians to consider.

Medicine Backs Proposed Medicare Prior Authorization Reforms - 05/21/2026

Physicians caring for Medicare patients soon may find relief from onerous prior authorization requirements that frequently delay, discourage, or drive up the costs of care, thanks to proposed regulations governing Medicare Advantage (Part C) and prescription drug (Part D) plans.

TMA Addresses Health Care Costs in House Committee Hearing - 05/19/2026

Supporting a new Texas House select committee’s goal of making health care more affordable, TMA identified cost drivers, chiefly administrative burden. More opportunities will follow to offer solutions.

MultiPlan Litigation Moves Forward - 05/18/2026

TMA has joined the federal antitrust litigation alleging MultiPlan and major health insurers colluded to suppress out-of-network reimbursement rates. The case is now in discovery, and the court has selected the 36 bellwether plaintiffs.

Aetna Settles Medicare Advantage Upcoding Allegations - 04/07/2026

The settlement resolves federal claims that at different times over the last decade Aetna Medicare Advantage plans submitted, or failed to withdraw, inaccurate diagnosis codes to increase payments from the federal government. Although physicians may not be impacted, TMA payment staff still recommend they continue to ensure all coding remains accurate.

PBM Consolidation Concerns Medicine for Impacts on Drug Costs, Access - 03/03/2026

Low competition in the pharmacy benefit manager (PBM) market may drive higher costs with savings not fully passed to consumers. Medicine is vigilant as state and federal legislators have started addressing the entities’ evolving role.

Network Adequacy Enforcement Paused for State-Regulated PPOs and EPOs - 02/23/2026

A dispute between the Texas Department of Insurance and Texas Association of Health Plans has reopened rulemaking connected to a 2023 network adequacy law. TMA, which supported that law’s passage, will weigh in on the process.

Patients Can Now Pay Some Direct Primary Care Expenses with Health Savings Account Funds - 02/05/2026

Patients who see physicians in direct primary care medical practices can now use their health savings account funds to pay their associated membership fees, because of new federal regulations that took effect in early 2026.

One Insurance Company Holds Majority Share of Texas Market, Per AMA Study - 01/14/2026

Increasing insurance consolidation negatively impacts both physicians and patients, according to the American Medical Association, making advocacy crucial.

Direct Payment Model Available to All Texas Physicians Under New State Law - 12/30/2025

House Bill 541, now in effect, replaces the “direct primary care” nomenclature from a TMA-backed 2015 law with the more inclusive “direct patient care.” In a typical direct care model, patients pay a monthly fee, and in return, receive services like office visits and in-office procedures without involving insurance.

Cigna Clarifies Terms, Conditions of Its High-Level E/M Downcoding Policy - 12/30/2025

In communication with TMA, Cigna confirmed its policy will not apply to all physicians and those subject to it can request to be removed from the review process under certain circumstances. Nevertheless, the limited scope of the “exemption” could still represent a significant operational and financial challenge for some practices.

Texas Can’t Afford for Congress to Let ACA Tax Credits Expire - 12/08/2025

Lawmakers must realize what’s at stake by not firming up a deal that keeps the credits in place: higher health care costs, poorer health outcomes and further destabilization of our health system. This opinion-editorial first appeared in the Austin American-Statesman on Dec. 4, 2025.

2025 Legislative Wrap-Up: Amid Bad Insurance Bills Defeated, Gold Card Law Refinements Close Gaps - 12/08/2025

House Bill 3812 addresses some of the shortfalls and inconsistencies among payers in the intended implementation of Texas’ landmark prior authorization exemption law. The law took effect Sept. 1 but additional rulemaking by the Texas Department of Insurance is likely.    

Legislators Can Request Health Insurance Mandate Analysis Via New State Law - 11/18/2025

Though the filed version of the bill would have heavily favored insurance companies, TMA successfully worked to add data transparency provisions to promote a comprehensive and unbiased analysis. Lawmakers also focused on price transparency bills affecting how facilities can bill patients for services.

Value-Based Care Extended to Texas PPO, EPO Health Plans for Primary Care Physicians - 10/20/2025

The new state law authorizes primary care physicians to enter into value-based care (VBC) payment arrangements with state-regulated PPOs and EPOs, if they choose to. The new law includes several guardrails TMA advocated for that seek to promote fair dealing in VBC negotiations.

Federal Changes Allow Payment for Direct Primary Care Via Health Savings Accounts - 09/29/2025

The new law permits patients to use health savings account funds for direct primary care membership fees, provided the arrangement meets certain federal requirements.

Physicians Brace for Expiration of ACA Tax Credits, Uninsured Fallout - 09/25/2025

An estimated 1.3 million Texans could lose coverage due to the combined effects of Affordable Care Act marketplace changes under OBBBA and the expiration of the enhanced premium tax credits at the end of this year. “Physicians are definitely going to feel the effects.”

Cigna Downcoding Policy Threatens Payment; TMA Urges Repeal - 08/18/2025

The payer announced a new plan under which it may adjust certain higher-level evaluation and management codes based on the encounter criteria in a submitted claim.

TMA Cheers Appellate Court Ruling in Third NSA Lawsuit - 06/03/2025

Statement by Texas Medical Association (TMA) President Jayesh "Jay" Shah, MD, in response to Friday's order by the U.S. Court of Appeals for the 5th Circuit granting TMA’s petition for rehearing en banc in TMA’s third No Surprises Act (NSA) lawsuit, which vacates the circuit panel’s Oct. 30, 2024 opinion and will result in a hearing by the full panel of judges at a later date.

TMA Forges New Policies on Same-Day Services, Patient Attribution in Value-Based Care - 05/16/2025

The house adopted several other payment-related policies as well, all emerging from ongoing physician frustration with payer practices that hinder patient care.

Insurance Bill Undermining Patient, Physician Protections Heads to House - 05/13/2025

A top target for TMA, House Bill 139 would create a new “employer choice of benefit” health plan exempt from decades’ worth of insurance laws that promise a minimum set of coverage, prompt pay, prior authorization restraints, and other guardrails. Other bad bills with serious consequences for practices also top TMA’s opposition list.

Prior Authorization Fuels Physician Burnout, Decreases Access to Care, AMA Survey Finds - 04/03/2025

Prior authorization continues to intensify physician burnout, increase health care costs, and limit patients’ access to care, per AMA. Meanwhile, TMA advocates against health plans’ use of artificial intelligence in the prior auth process and aims to reduce its burden on physicians.   

Panel Makes Big Change in Draft Federal Surprise Billing Law - 03/18/2025

Thanks to incessant lobbying from physicians, hospitals, organized medicine, and the Physicians Advocacy Institute, a key congressional committee today made significant revisions in a bill to reduce the strain of surprise billing on patients. “This certainly sounds like an improvement,” said Texas Medical Association President David Fleeger, MD, “but the devil will be in the details.”

BCBSTX Reprocessing Flu Testing Claims Following Incorrect Denials - 03/03/2025

Blue Cross and Blue Shield of Texas (BCBSTX) is reprocessing certain claims filed between Jan. 1 and Feb. 13, the payer told TMA’s Physician Payment Resource Center. Physicians should continue to review claims to ensure they are correctly reprocessed.