By Tammy Taylor, CEO
For personal credit cards or airline miles, you pay your bills on time or fly enough flights and eventually you’ll likely achieve gold-level status, complete with a variety of perks. Now, the concept is coming to prior authorization (PA), designed to alleviate some of the administrative burdens and unnecessary delays in care delivered by providers with a proven track record of performance.
Prior authorization has been around for decades, originally used sparingly as a way for insurers to determine if costly medical procedures or medications seemed truly necessary. Today, PA has deteriorated into what too often amounts to a road block for timely delivery of even the most routine medications and procedures. The explosion of PA requirements has left both providers and patients frustrated, increasing administrative costs and often causing dangerous delays in care and often resulting in adverse clinical outcomes.
A KFF analysis of data from the Centers for Medicare & Medicaid Services (CMS) found that in 2021:
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- Medicare Advantage insurers saw more than 35 million PA requests submitted on enrollees’ behalf.
- Medicare Advantage plans partially or fully denied more than 2 million of those requests.
- Among the denials, 11% were appealed. Of those that were appealed, 82% saw the initial PA denial fully or partially overturned.
- 99% of Medicare Advantage patients are enrolled in a plan with prior authorization on at least some services.
Not surprisingly, an American Medical Association (AMA) survey of more than 1,000 physicians shows that 88% of them find the burden associated with PA as “high” or “extremely high.”
The importance of effective PA management is why it’s one of the many essential services we provide our clients as their RCM partner.
How Do Gold Cards Work?
The programs are called slightly different things by various insurers and the states in which they must be approved for use, but “gold card” or “gold carding” are good generic terms. So far, 10 states have passed gold card legislation, though not all legislation has yet gone into effect:
- Colorado
- Illinois
- Maine
- Maryland
- Minnesota
- Mississippi
- Oklahoma
- Virginia
- West Virginia
- Wyoming
More states could pass laws before the year is over, including Massachusetts.
Other states continue to consider gold card programs to turn down the noise a bit from their frustrated physician groups, acknowledging the financial, clinical, administrative and satisfaction impacts of broad use of PA in recent years. It’s also an acknowledgement of the impact that administrative hassles have had on the growing shortage of physicians in most specialties across the U.S. From PA to exploding malpractice insurance rates, many physicians or potential future physicians have simply had enough.
Read the Label
As with any prescription, it’s important to pay attention to the instructions for each gold card program. Each state has set different requirements and approval criteria. However, one constant across all legislation is that gold card approval is specific to one provider for each healthcare service, procedure, or prescription product and does not provide a blanket exemption for all prior authorizations submitted by a physician.
State requirements for gold card exemptions vary from needing five prior authorization requests for a healthcare service during a six-month period with a 90% or greater approval rate (Texas) to requiring an average of 30 procedures per year with a 90% or greater prior authorization approval rate over a six-month period (West Virginia). Prior authorization approval rate requirements may reach as high as 95 to 100% to qualify for a gold card program. The bar is set high to achieve gold card status, as it should be, and some providers may find it difficult to reach.
Gold card PA exemptions typically last from six to 12 months and may be at the discretion of the health plan. Some states allow for plan discretion as it relates to the criteria and services to be included.
Willy Wonka Golden Ticket, or Yet Another Complicated Program to Wrestle?
We understand that many providers may be skeptical. They’ve often been promised solutions to administrative burdens before, only to end up with more, not less.
We’re Here to Help
That’s why as your RCM partner, Advantum Health is keeping fully abreast of the changes as they occur…procedure by procedure, provider by provider. The gold card movement is at least an attempt to more fully leverage the increasing wealth of data available today in EHRs and RCM solutions to speed care approvals and reduce administrative burdens. Providers and patients alike will benefit, and our Advantum team and proprietary Advantum Ai platform are ready to provide ongoing assistance and address any questions or concerns you may have as together we implement gold card changes as they occur.