Ask a provider what’s causing tension in their relationship with insurers and many will point to prior authorization, arguing that the practice creates administrative burdens and delays in patient care.
In an effort to improve prior authorization, many insurers and states have introduced gold carding programs, in which providers with a proven track record of prior authorization approvals are exempt from some prior authorization requirements. This includes in the state of Texas, where there is a law that exempts providers from requesting authorization for certain procedures if they have a 90% or greater final approval rate for those requests.
But are these programs working? So far, the Texas Medical Association (TMA) is disappointed with the gold carding law in Texas.
“You would think, given how often prior authorization requests are eventually approved, that we would have a pretty sizable number of physicians who had achieved the status,” said Ezequiel “Zeke” Silva III, MD, chair of TMA’s Council on Legislation. “Regrettably, the last data that we’ve seen regarding the number or percentage of physicians who have achieved the status is low, it’s 3%.”
Despite the disappointment of some providers, efforts are ongoing to improve gold carding. For example, in Texas it means refining the law further. Some plans are developing new programs to help providers achieve gold card status. But others believe that prior authorization is a flawed tool developed in response to an innately broken system. At least one health plan CEO said he wants to focus on value-based care instead.
The problem with gold carding programs
When the Texas Gold Card Law was first created in 2021, Silva and TMA had “considerable optimism” and were hopeful that it’d make a difference in prior authorization.
However, in the years following its implementation, the law has fallen short. One issue is that there is very little transparency and data to understand how gold carding works.
“When it passed, it was passed in a way that the health plans had the responsibility to determine the gold card exemptions, notify physicians and manage it accordingly. There was no application process for physicians,” Silva said. “There was no claims based process for physicians. It was purely on the plans to administer it.”
And very few physicians have actually received a gold card, just 3%, according to Silva. And even that stat is outdated given that it is from 2022. This underscores the lack of robustness in the current law.
There also seems to be a level of inconsistency in how gold cards are being provided to physicians. Silva gave two examples of physicians he’s spoken to about gold carding in Texas.
“I’ve talked to an orthopedic surgeon who I know does have a gold card, and one comment he made was that he didn’t pursue it with the health plan,” he said. “He didn’t call them and check. One of his staff just happened to look at a fax machine one day and it had a letter that said he had achieved the status. … I have another physician who has been a little bit more proactive and has told his administrators to look everywhere: emails, fax machines, whatever.”
The latter physician tried to reach out to several health plans to determine his status, and eventually just gave up, according to Silva.
The other issue is that the law only applies to state regulated plans, not government payers like Medicare and Medicaid, nor ERISA plans. Therefore, it only affects a small percentage of health plans in Texas.
The Texas Medical Association’s issues with gold carding are reflective of what one vendor is seeing across the country. Cohere Health is a health tech company focused on improving prior authorization. The company’s chief product officer, Matt Parker, said the idea of gold carding isn’t bad, but it hasn’t necessarily worked out in practice.
Like Silva, he said that there has been a lack of transparency in how programs are designed, and that getting into gold card programs is actually very challenging for providers. He noted that oftentimes, there is little clarity on how to achieve gold card status, and that the number of providers participating is having little impact.
“The problem of gold carding really wraps up into [that] it’s not a super sophisticated or flexible or transparent way of identifying providers that are consistently prescribing appropriate care,” Parker said.
The challenges aren’t necessarily just on the provider side, however. There are also instances of utilization and spending spiking after a provider achieves a gold card, he added. In other words, after a provider achieves gold card status, then it’s viewed almost as a license to order more tests or do more procedures.
Because of these challenges with gold carding and prior authorization, Cohere Health recently launched a new product called Cohere Align. The product analyzes provider behaviors and groups them into performance-based cohorts so health plans can create targeted interventions for those cohorts. High performing cohorts have fewer prior authorization requirements, while low performing cohorts receive more education and coaching so that they can improve clinical outcomes. Cohere Align also continuously tracks performance over time.
There are some approaches to gold carding that are achieving success. Highmark, a Pennsylvania-based insurer, has a program that provides gold cards to practices and physicians when they have a 99% or higher approval rating for specified CPT codes and modalities, such as for CT scans, MRIs or nasal endoscopies. This is available for commercial, Affordable Care Act and Medicare Advantage plans.
The insurer automatically enrolls providers twice annually when they meet criteria, and Highmark sends notifications to providers who are enrolled in the program. Then once a provider is gold carded, Highmark tracks the provider’s ordering trends and conducts random audits on utilization. With a gold card, providers only need to send a prenotification to schedule services and approval is immediately granted.
“The concept of gold carding is very simple, and it’s basically about sharing actual data that starts moving the needle so that you can go as upstream as possible,” said Dr. Tony Farah, executive vice president and chief medical and clinical transformation officer at Highmark Health, in an interview. He added that this is something other payers could easily replicate.
Highmark operates in Pennsylvania, Delaware, New York and West Virginia. West Virginia has a gold carding mandate, which Highmark is compliant with, while the other states do not.
The insurer also has a program called Active Gold Carding for providers. Through this, Highmark works directly with clinicians and offers support from a concierge nurse. Highmark offers real-time feedback and live in-person and virtual coaching to help physician practices submit accurate and clinically appropriate requests. Once providers finish engaging with the Active Gold Carding program, they become gold carded.
Clinicians who are gold carded through Highmark spend less than three minutes submitting prenotification and receiving approval, according to data shared with MedCity News. Currently, more than 23,000 clinicians are gold carded, or 11% of physicians in the insurer’s network. There are also 1,600 active gold carded clinicians within its network.
At least one physician in Highmark’s network — Dr. Timothy Sauber, an orthopaedic surgeon with Allegheny Health Network Orthopaedic Institute — is mostly happy with the gold card program. He is gold carded for MRI, CT, nuclear medicine, total knee and total hip.
However, he noted that he would like to get to a point where the requirement to send a prenotification is eliminated. Still, the process is “very minimal and simplistic,” he said.
“You’re still spending the small amount of time to do the authorization, but you’re not having to say, ‘We’ll have to get back to you about whether that’s going to get approved.’ You don’t ever have the risk of having a denial come down through the authorization process. So it does definitely save you time in the back end,” he said in an interview.
Changes that need to be made
The Texas Medical Association is working with the state to improve its gold carding law. One change the organization would like to see is for the Texas Department of Insurance to maintain a database of prior authorization approvals, denials, appeals, third party reviews and other information. This would help inform providers about how they can achieve a gold card status, according to Silva.
The organization is also working to get certain conditions exempt from prior authorization. Last legislative session (2023), autoimmune conditions were exempted from prior authorization. This session, TMA is working on other conditions or services, such as chronic conditions or preventive screenings.
“We think that’s very patient focused and patient centered, which we think will resonate,” Silva said.
Another industry executive, meanwhile, thinks there needs to be a broader conversation about prior authorization that goes beyond gold carding. Dr. Sachin Jain, CEO of SCAN Group and SCAN Health Plan, said that gold carding is “very easy to talk about, but very hard to execute upon.”
“If you’re treating different providers in your network differently, I think it creates friction with your network,” he said. “And ultimately, there’s already a lot of friction in the network, and so what we’re trying to do is minimize that friction.”
SCAN does not have a gold carding program and actually delegates risk to the provider groups it works with so that they’re conducting prior authorizations themselves. And he thinks accelerating the push to value-based care would actually greatly improve the tension that exists with prior authorization.
“We would have a very different health system if we really empowered primary care to do primary care, if we really invested more in outpatient chronic disease management. … Patients would need fewer procedures because they would be healthier. Unfortunately, most people don’t have access to primary care doctors these days. And then when they do, they get lost in this ping pong game of approval, denial, approval, denial,” Jain said.
Photo: Piotrekswat, Getty Images
