Prior Authorization

“Gold card” approach to prior authorization introduced in Congress

Kevin B. O'Reilly , Senior News Editor

What’s the news: A bipartisan bill introduced in the U.S. House of Representatives would help minimize the burdens associated with prior authorization in Medicare Advantage plans.

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The “Getting Over Lengthy Delays in Care as Required by Doctors Act of 2022” is sponsored by Texas Reps. Michael Burgess, MD, a Republican, and Vicente Gonzalez, a Democrat.

The bill—called the “GOLD CARD Act” for short—exempts physicians from Medicare Advantage plan prior authorization requirements so long as 90% of the doctors’ requests were approved in the preceding 12 months.

Medicare Advantage plan-issued “gold cards” would only be applicable to items and services—excluding prescription drugs—and remain in effect for at least a year. The legislation is based on a similar law enacted in Texas that took effect in 2021.

Fixing prior authorization is a critical component of the AMA Recovery Plan for America’s Physicians. You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And the AMA is ready.

Prior authorization is overused, and existing processes present significant administrative and clinical concerns. Find out how the AMA is tackling prior authorization with research, practice resources and reform resources.



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Why it’s important: “Almost daily, prior authorization frustrates physicians by complicating patient care with unnecessary administrative hassles,” AMA Immediate Past President Gerald E. Harmon, MD, said in a news release that Reps. Burgess and Gonzalez issued in June. “This bill incorporates the commonsense reforms that will benefit Medicare Advantage patients and reduce burnout among physicians, including exempting physicians with high prior-authorization approval rates from these utilization-management requirements.

“We went to medical school to provide the best care possible for our patients, not to waste time checking boxes,” Dr. Harmon said. “Not only does this bill help streamline prior authorization, the ‘GOLD CARD Act’ provides physicians with ample opportunities to appeal attempts by Medicare Advantage plans to rescind this exemption.”

The AMA commended the Texas congressmen “for introducing this bipartisan bill that will lead to higher quality care, better health care outcomes, and improved physician and patient satisfaction,” Dr. Harmon said.

The most recent AMA prior-authorization physician survey (PDF) illustrates the negative impact of prior authorization on physicians and patients. More than one-third (34%) of physician respondents said that prior authorization led to a serious adverse event, such as hospitalization, disability, permanent bodily damage or death, for a patient in their care.

The 2021 AMA survey also highlights that 93% of physicians reported care delays associated with prior authorization, and 82% said these requirements can at least sometimes lead to patients abandoning treatments.

Find out why prior authorization is bad for patients and bad for business.

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Learn more: Following direct advocacy from the AMA, the “GOLD CARD Act”—H.R. 7995—also establishes numerous processes to ensure that Medicare Advantage plans cannot inappropriately revoke this exception to prior-authorization practices.

Although permitted under the bill to rescind the exemption, Medicare Advantage plans must demonstrate that fewer than 90% of claims submitted during a 90-day plan period would not have received prior authorization. This 90-day look-back period must be extended until at least 10 claims are ultimately provided. Services that are initially denied and pending appeal for at least 30 days are required to be considered “approved” with respect to the 90% threshold.

The bill also explicitly excludes services affected by a change in coverage determinations that were submitted during the 90-day look-back period. Most importantly, Medicare Advantage plan physicians who review the potential gold card rescission are required to be actively engaged in the practice of medicine in the same or a similar specialty as the physician under review, have knowledge about the specific service in question and possess a current, nonrestricted license in the same state as the furnishing physician. Physicians who possess the gold card can also appeal any attempt to rescind the exemption.

Read more about how Texas’ new physician gold card law will cut prior-authorization delays

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