Prior authorization has long been considered a burden by many providers, but new "gold card" laws in some states may help qualified providers reduce prior authorization delays and potentially improve care for their patients, Maya Goldman reports for Modern Healthcare.
Some states look towards prior authorization 'gold card' laws
The American Medical Association (AMA), America's Health Insurance Plans (AHIP), and other industry stakeholders have previously stated that prior authorization requests, when applied appropriately, can help maximize value in health care. However, they also acknowledged that the process can be burdensome for all parties.
According to a 2021 survey from the Medical Group Management Association, almost 90% of providers said prior authorization was very burdensome. And in a similar survey from AMA, 24% of physicians said prior authorization was not just burdensome, but that it often caused their patients to abandon care.
Now, some states are implementing prior authorization "gold card" laws, which exempt providers from pre-authorization of some services if they reach a certain approval rating over six months.
The first state to implement such a law was West Virginia in 2019. Under the law, providers are not required to seek prior authorization for a certain service if they have a 100% approval rating for the service over six months. Then, in 2021, Texas passed a similar, but more lenient law, requiring providers to achieve a 90% approval rating over six months to be exempt.
Currently, Vermont is running statewide gold card pilot programs for both Medicaid and private insurers. According to a 2020 report from the Vermont Department of Health Access, the gold card program provided "a notable example of success in improving clinal results and reducing administrative burden for healthcare professionals" who used it for Medicaid radiology services.
In addition, at least eight other states, including Connecticut, Kentucky, and New York, have introduced gold card bills, Modern Healthcare reports, and other state medical associations, including in Ohio, are currently working on similar bills.
Chris Phillips, a rheumatologist from Kentucky, said he's relieved that his state is considering a gold card bill. "It would save several hours a day of work by my staff, which could be better directed toward patient-centric activities, and actually taking care of the patients," he said.
Are gold cards programs the solution to prior authorization problems?
Although AMA and other industry groups have endorsed gold card programs in the past, other health groups, including the American Heart Association and the Duke-Margolis Center for Health Policy, have said gold cards could potentially make health inequities worse. In particular, smaller practices could be negatively impacted by gold card programs because they lack the same resources as larger health systems to earn approvals and appeals.
In addition, not all insurers support gold cards for prior authorization. For example, the Texas Association of Health Plans in 2021 said the state's new gold card law could cause an "inappropriate 'guarantee of payment' for potentially inappropriate or even harmful care."
The health insurance trade group AHIP has also cautioned against providers relying too heavily on gold cards. "Gold carding isn't a silver bullet, and it's not appropriate for every care provider," said AHIP spokesperson David Allen. He added that gold cards should be used to recognize excellent care and encourage best practices.
Aside from gold card policies, states are also looking at a wide variety of prior authorization reforms, including electronic prior authorization policies.
"I don't know (that) there's too many states right now that don't have some kind of insurance administrative reform, all in little bits of different flavors," said Todd Baker, CEO of the Ohio State Medical Association. (Goldman, Modern Healthcare, 5/3)