The health insurance landscape has seen prior authorization (PA) grow from a minor hurdle into a sprawling administrative maze. Once a way to ensure medical necessity, PA now contributes to delays, paperwork, and frustration that has affected both physician and patient experiences. Enter the “gold card” concept–a potential game-changer aimed at streamlining PA by exempting physicians with strong approval histories from routine reviews. Could this be the innovation we’ve all been waiting for?
The rationale for prior authorization
On the surface, the rationale for PA makes sense. Insurers argue that the process helps control costs, improve care quality, and enhance patient safety by requiring that specific treatments or tests are judged medically necessary before approval. Payers tout PA as a tool to avoid unnecessary procedures and reduce spending on ineffective or overly risky interventions.
However, PA requirements have ballooned into a constant source of frustration for physicians. A survey by the American Medical Association found that 88% of physicians describe the PA burden as high or extremely high, spending nearly 14 hours weekly on these requests. And it’s not just physicians feeling the strain; patients, too, face delays in care that can be especially troubling when waiting for urgent or complex treatments.
Despite PA’s intended purpose, both camps agree that the process has problems. The result? The healthcare industry's near-ubiquitous call for reform and a push toward automation, streamlined processes, and, lately, gold card programs.
What exactly is a gold card?
Gold cards are “reward” programs for high-performing physicians. Under UnitedHealthcare’s new program, for example, doctors who have submitted at least 10 prior authorization requests for specific procedures in each of the past two years—and have an approval rate of 92% or higher—can forgo documentation requirements for certain services. Instead, they simply submit an "advance notification," bypassing the usual review and paperwork.
Other insurers, including Health Care Service Corp. and Highmark, have similar programs, and the momentum is growing. Gold cards give a nod to trusted doctors, lightening the load for procedures with a track record of approval, as insurers acknowledge that some physicians don’t need omnipresent supervision.
The upside of gold cards for physicians and patients
For those eligible, gold cards could be a welcome relief from administrative burnout. Here are some of the key benefits that physician leaders and healthcare executives may want to consider:
- Administrative efficiency: Eliminating the need for repetitive documentation can save time and reduce costs, allowing physicians to spend more time on patient care and less on paperwork.
- Improved patient access and satisfaction: When physicians can skip the usual PA process, patients benefit from faster access to necessary treatments without the frustration of delays.
- Building trust: Gold cards could shift the adversarial relationship between doctors and insurers, fostering a more collaborative environment. By recognizing physicians as experts capable of making appropriate care decisions, insurers are opening the door to trust-building. However, it remains to be seen if this trust will be long-lasting.
But is this truly a silver bullet for the PA problem?
Challenges and limitations of gold cards
As promising as gold cards sound, they’re not the perfect solution. Here’s where the concept starts to feel a bit more grounded:
- Physician skepticism: Doctors and provider groups have seen numerous attempts at PA reform fall short. Skepticism is, frankly, the default. Many healthcare groups wonder if gold cards will make a meaningful difference or are another minor tweak in the grand scheme of administrative burden.
- Eligibility hurdles: The criteria for gold cards are selective. Achieving and maintaining a 90-92% approval rate over two years for 10 or more procedures isn’t always realistic, particularly for proceduralists and surgeons dealing with complex cases or vulnerable patient populations who need more nuanced care. The program may benefit the “usual suspects” while excluding those who need the most relief.
- Limited scope of exemption: Not every procedure is eligible, even with gold cards. UnitedHealthcare’s program, for example, covers around 500 procedures – a small slice of the clinical services requiring PA. For physicians whose requests fall outside these bounds, the administrative burden persists.
Regulatory landscape and future directions
Gold cards aren’t just an insurer-driven innovation; state and federal governments have recognized the need for PA reform. Over the past few years, several states have passed laws mandating gold card-like programs, ensuring that doctors with high approval rates are granted exemptions.
At the federal level, the Centers for Medicare & Medicaid Services (CMS) recently finalized a rule to expedite PA reviews for Medicare Advantage patients. CMS mandates, for instance, that Medicare Advantage plans must honor approved PAs for the entire course of treatment and must provide a 90-day grace period for members who switch plans.
This regulatory momentum suggests a possible future where gold cards, or similar PA reform strategies, become the standard rather than the exception. With Congress debating legislation requiring real-time electronic PA processing, the writing is on the wall for insurers: reform PA, or legislators will do it for you.
The road ahead: Is the gold card here to stay?
Gold cards offer a glimpse into what a less burdensome PA process might look like. While their impact remains limited to specific procedures and provider groups, there’s potential for broader adoption, especially if these programs demonstrate real savings outcomes.
If the gold card concept takes off, we could see an industry-wide trend toward more nuanced PA policies prioritizing evidence-based care and reducing oversight for trusted physicians. This would save time and money and improve care by cutting back on delays.
To ensure gold cards reach their potential, insurers should consider the following:
- Expand the scope: Include more procedures and make qualification requirements achievable for a larger group of physicians, especially those serving vulnerable populations.
- Increase transparency: Insurers should make eligibility criteria clear and accessible so doctors understand how to qualify and can work towards meeting requirements.
- Monitor and adapt: Collect data on the program’s impact and be willing to adjust it. If the data suggest that patient outcomes remain high without PA, this should pave the way for further PA reductions.
Gold cards as a step toward a better prior authorization process
Gold cards represent a step in the right direction, aligning with the goals of reducing administrative burden, improving patient access, and strengthening the trust between insurers and physicians. The road to widespread adoption may be long, but gold cards could ultimately pave the way for a reimagined PA process that prioritizes efficiency, transparency, and collaboration over bureaucracy.
For healthcare executives and physician leaders, gold cards offer an opportunity to engage payers in constructive discussions on how to improve the PA process. This ensures that efforts to streamline care delivery benefit patients, doctors, and payers alike. If we continue to build on this momentum, we might just move the needle toward an efficient, patient-centered, and sustainable prior authorization system.