Guide to prior authorization and gold card exemption policies

The AOA recently released a guide outlining challenges with prior authorizations (PA) and the problems it can cause to patient access to care. The AOA has been an advocate for PA reform to address the burdensome and often harmful PA requirements imposed by health plans. These requirements have increased significantly over the past decade, affecting nearly all medical services and drug classes, and contributing to delays in patient care and increased administrative burdens for physicians.

Key points

Physician burden and patient risk: PA requirements create substantial administrative burdens, often leading to delays in care and adverse patient outcomes. Surveys show that nearly half of physicians report patient harm due to PA-related care delays.
Gold card program benefits: These programs can significantly reduce the time and cost associated with PA processes, allowing physicians to focus more on patient care. Successful Gold Card programs require clear criteria for physician qualification, appropriate thresholds for PA approvals, and robust oversight to ensure effective implementation.
Federal and state actions:
- Federal level: The Gold Card Act, reintroduced in the U.S. House of Representatives in July 2023, aims to exempt physicians from PA under Medicare Advantage plans based on their approval rates.
- State level: States like Texas and West Virginia have implemented Gold Card laws with varying degrees of success. Texas law, for example, has shown limited impact due to stringent criteria and flexible plan definitions of PA requirements.

Challenges and recommendations

To enhance the effectiveness of gold card programs, the guide points out several recommendations:

Lengthening the evaluation period for exemptions.
Reducing the granularity of PA service definitions.
Lowering the request thresholds.
Combining PA data across all plans to provide a comprehensive evaluation of physician performance.

Comprehensive reform of PA policies, including well-designed gold card programs, is essential to reduce administrative burdens and improve patient outcomes. The AOA is committed to advocating for these reforms to ensure that osteopathic physicians can provide timely, effective care without unnecessary bureaucratic obstacles. Be sure to share your story to help further guide our advocacy efforts on prior authorization reform.