Insurance company prior authorization processes delay patient care while driving up physician burnout. Texas and other states have responded by passing “gold card” legislation that exempts physicians from prior authorization for certain procedures and treatments if they have a proven record of delivering appropriate care.
A bipartisan bill, sponsored by a physician lawmaker, has been introduced in Congress that seeks to exempt physicians from Medicare Advantage plan prior authorization requirements if 90% of the physicians’ prior authorization requests were approved in the preceding 12 months.
“Here's the proposition, and we've all heard this I don't know how many times: 10% of the people are causing 90% of the problems,” said Rep. Michael Burgess, MD, a Texas Republican, during a recent episode of “AMA Update.”
“This kind of turns that around and says, ‘Hey, if you're one of the 90% that is doing everything right and by the book, and your procedures are always approved—or 90% of the time approved—you don't need to keep going through this process,” explained Dr. Burgess, a retired ob-gyn. “We're going to trust you that the next case will be just as indicated as the last case."
Dr. Burgess and Rep. Vincente Gonzalez, a Texas Democrat, have sponsored H.R. 4968, the Getting Over Lengthy Delays in Care as Required by Doctors (GOLD CARD) Act of 2023, The bill, supported by the AMA, 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. Learn how the AMA is tackling prior authorization with research, practice resources and reform resources.
Urge legislators to co-sponsor bill
The two Texas congressmen have recruited 21 co-sponsors, and Dr. Burgess said he’s looking for more and asked physicians to urge their representatives in Congress to sign on to the bill.
“I'd certainly appreciate bringing up the gold card concept, because—if we can get enough co-sponsors on the bill—then we can get it to move in the legislative process,” he explained.
Dr. Burgess noted the importance of contacting legislators when they return home to their districts when they’re not distracted by events in the Capitol.
“Go visit with them—perhaps take a patient or two with you,” he suggested. “Don't make it all about doctors and how Congress is making our lives tougher—but how it's affecting the care of the patient.”
Most of all, Dr. Burgess emphasized, “make it important to your member of Congress.”
Patients, physicians and employers can learn more about reform efforts and share personal experiences with prior authorization at FixPriorAuth.org.
Visit AMA Advocacy in Action to learn what’s at stake in fixing prior authorization and other advocacy priorities the AMA is working on.
Automate prior authorization
Physicians have given him “a lot of positive reinforcement” on the GOLD CARD bill, and Dr. Burgess said he’s looking at other ways to reform and streamline prior authorization as well.
“Make the collection of data automatic—not something that someone has to actually collect and submit, but make it automatic through an automated claims process,” he said. “There are things that can be done to make it more straightforward.”
In 2018, insurers committed to using automation to improve prior authorization transparency and efficiency and to move toward industry-wide adoption of electronic prior authorization transactions based on existing national standards.
But, according to a recent AMA survey of more than 1,000 practicing physicians, few health plans have done so. Telephone and fax are still the most common ways to complete prior authorizations.
In other survey responses, 89% of physicians said prior authorization sometimes, often or always leads to missed doses of medications, interruptions in chronic treatment or otherwise interferes with patients’ continuity of care.
And 33% reported that prior authorization led to a serious adverse event including hospitalization, permanent impairment or death.
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