House bill advances “gold card” model on prior authorization

AMA News Wire

House bill advances “gold card” model on prior authorization

Aug 30, 2023

Bipartisan legislation called the “GOLD CARD Act” to give physicians relief from the time-wasting burden of prior authorization has been introduced in this session of Congress.

H.R. 4968, the Getting Over Lengthy Delays in Care as Required by Doctors Act of 2023, would exempt physicians from Medicare Advantage plan prior authorization requirements so long as 90% of the physicians’ prior authorization requests were approved in the preceding 12 months. Medicare Advantage plan-issued gold cards would be applicable only to items and services—and exclude 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.

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.

Introduced by Republican Rep. Michael Burgess, MD, and Democratic Rep. Vicente Gonzalez, both of Texas, the GOLD CARD Act also establishes numerous processes the AMA has advocated to ensure that Medicare Advantage plans cannot inappropriately revoke this exception to prior authorization practices. 

Although permitted 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 review 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 similar specialty as the physician under review.
• Have knowledge about the specific service in question.
• 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.   

Patients, physicians and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.

“Prior authorization continues to serve as a chief frustration for physicians due to its excessive use, opacity, responsibility for delaying and denying patient care, and direct correlation with poorer health care outcomes,” said AMA President Jesse M. Ehrenfeld, MD, MPH.

“The GOLD CARD Act is an important step to right-sizing these insurance-created obstacles to care for Medicare Advantage patients,” he added. The AMA “supports federal legislation that exempts physicians with high prior authorization approval rates from these harmful and burdensome requirements. One can almost hear the bureaucratic red tape being cut—a rare sound coming from D.C.”

He commended Reps. Burgess and Gonzalez “for introducing this bipartisan bill that will help reduce physician burnout and improve patient satisfaction.” 

While payers claim that prior authorization requirements are used for cost and quality control, a vast majority of physicians report that the protocols lead to unnecessary waste and avoidable patient harm.

One-third of the 1,001 physicians surveyed (PDF) by the AMA in December reported that prior authorization has led to a serious adverse event for a patient in their care.

Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.