Prior authorization remains a crucial aspect of healthcare management to reduce unnecessary healthcare expense and to ensure patients receive evidence-based care. However, navigating the administrative process can often pose challenges for medical providers. Recognizing these issues, payers are seeking innovative approaches to utilization management by collaborating with providers to enhance efficiency without compromising quality. Payers and state legislatures have frequently turned to the practice of gold carding as a method of granting prior authorization to certain providers who have demonstrated high compliance with clinical guidelines and low utilization rates, allowing them to bypass the review process for select procedures or diagnoses.

While gold carding has been a common strategy, emerging alternatives such as HealthHelp’s Quality Performance Program offer strategic alternatives for process improvement.

Understanding Prior Authorization and Gold Carding: Prior authorization mandates approval from insurers before covering specific medical services, medications, or procedures. Conversely, gold carding grants automatic approval to high-performing providers within a network for designated treatments, bypassing the standard prior authorization process.

While gold carding streamlines access to care, it presents challenges:

1. Administrative Burden: Maintaining gold carding lists demands significant administrative resources, posing a strain on both providers and insurers. Even in states where legislation has been passed on this topic, resource limitations hinder widespread compliance.
2. Risk of Overutilization: Automatic approval may lead to unnecessary treatments, driving up costs and potentially compromising patient safety.
3. Equity Concerns: Variability in approval based on provider status can create disparities in access to care among patients with similar needs.

Legislative Initiatives for Gold Card Laws:

At both the federal and state levels, legislative initiatives are underway to enact “gold card” initiatives to grant automatic approval or expedited authorization to high-performing healthcare providers within designated networks.

At the federal level, several bills have been introduced in the U.S. Congress with provisions related to “gold card” laws. These bills aim to establish standardized criteria for identifying high-performing providers and facilitating expedited authorization processes. Regulatory reforms may include incentivizing health plans and providers to adopt streamlined authorization processes through reimbursement incentives or accreditation standards. Congressional committees responsible for healthcare and insurance oversight are actively deliberating on these proposals.

Several states, including California, Florida, Michigan, New York, Texas, and Pennsylvania, are considering or have proposed legislation to establish gold card programs for healthcare providers who demonstrate high-quality and cost-effective care. These programs allow qualifying providers to bypass prior authorization for designated services and procedures. Some of these states, such as California, Florida, Michigan, and Texas, have introduced bills that are currently under review in legislative committees, while New York and Pennsylvania have passed laws that authorize the creation of gold card programs. Pennsylvania’s Act 146, signed into law in November 2022, also requires insurers to adopt electronic prior authorization systems and sets time limits for authorization decisions.

Overall, legislative initiatives at both the federal and state levels aim to address the administrative burdens associated with prior authorization while promoting efficient and equitable access to healthcare services. As these initiatives evolve, stakeholders continue to engage in dialogue to shape policies that balance the interests of payers, providers, and patients. Alternatives to a one-size-fits-all approaches to prior authorization, such as gold carding, continue to be evaluated and include increased use of provider and patient analytics and value-based reimbursement.

Exploring Better Alternatives for Payers: HealthHelp’s Quality Performance Program offers an alternative approach by leveraging data-driven analytics to optimize the prior authorization process. This solution empowers payers to incentivize high-quality providers, reduce administrative burden through accelerated approvals while providing performance insights, auditing, and clinical education opportunities.

Our program understands the importance of customized solutions and strong, collaborative partnerships based on data. By providing insight into network activities and usage trends, along with flexible platform configuration settings, ongoing performance auditing and provider education, our program guarantees a fair method of prior authorization.

Highlights of our solution include:

• Configurable Criteria for Eligibility:  Configurable criteria enables HealthHelp to tailor the authorization process to meet the unique requirements of different healthcare providers, payers, and patient populations. This flexibility allows for more precise decision-making and ensures that authorization criteria align closely with clinical guidelines and best practices.
• Provider Performance Scorecards: Gain comprehensive insights into provider performance metrics, enabling informed decision-making and strategic network segmentation.
• Auditing Capabilities: Ensure compliance and accountability across the provider network through auditing, mitigating risks and enhancing quality control, all supported with the help of HealthHelp’s experienced clinical staff.
• Client Service Support: Our dedicated team of experts is committed to delivering support, guiding clients through implementation, optimization, and ongoing utilization of our Quality Performance Program.

The landscape of prior authorization in healthcare is evolving, with a pressing need for efficient solutions that balance cost containment and quality care. While traditional methods like gold carding have shown limitations, innovative alternatives such as HealthHelp’s Quality Performance Program offer promising avenues for improvement. By leveraging data-driven analytics, configurable criteria, and comprehensive support services, this program not only streamlines the authorization process but also ensures adherence to clinical guidelines and best practices. As legislative initiatives continue to shape the healthcare landscape, it’s imperative for stakeholders to collaborate in advocating for solutions that prioritize both efficiency and patient outcomes. Through ongoing dialogue and strategic partnerships, we can collectively advance towards a healthcare system that optimally serves the needs of all involved.

Interested in optimizing your prior authorization process? Let’s discuss how our solution can benefit your health plan.