Patients need ‘timely and high-quality care,’ not ‘bureaucratic red tape,’ lawmakers say.
Medicare Advantage could create a new “Gold Card” program to smooth out the prior authorization (PA) process for physicians and patients.
Two Texas lawmakers have introduced the GOLD Card Act of 2023 to exempt qualifying physicians from PA requirements if they have had at least 90% approvals in the last year. The 90% includes approvals granted on appeal, and physicians would have an appeal process if the Gold Card status was revoked.
The bill was introduced by Republican Rep. Michael Burgess, MD, and Democratic Rep. Vicente Gonzalez.
“By streamlining the prior authorization process for physicians, this bill will enable patients to receive timely and high-quality care,” Burgess said in a joint news release with Gonzalez, who called it a commonsense bill.
“Bureaucratic red-tape should not hinder patients’ ability to receive attention or our medical professionals’ ability to perform preventative or even life-saving care,” Gonzalez said.
Their announcement included a half dozen statements from medical specialists repeating a common complaint.
“Prior authorization often results in delays in care, which causes needless pain, delays in treatment, and suffering for patients and is a significant problem in today’s delivery of health care,” said a statement from Terrence A. Cronin, Jr., MD, FAAD, president of the American Academy of Dermatology Association. Cronin’s statement was similar in theme to those of Texas Medical Association President Rick W. Snyder, MD; American Association of Orthopaedic Surgeons (AAOS) First Vice President Paul Tornetta III, MD, PhD, FAAOS; Christopher S. Kang, MD, FACEP, president of the American College of Emergency Physicians; Russell R. Lonser MD, FAANS, chair of the department of neurosurgery at The Ohio State University and chair of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Committee; and Michael X. Repka, MD, medical director for government affairs of the American Academy of Ophthalmology.
The bill has the endorsement of the Medical Group Management Association (MGMA) so physicians can focus resources on patient care. Right now, just 7% of MA plans offer gold-carding programs, according to MGMA.
"Year after year, medical practices identify prior authorization requirements as the most challenging and burdensome obstacle to delivering high-quality patient care,” Anders Gilberg, MGMA senior vice president of government affairs, said in a statement. “By passing this commonsense legislation, Congress can ensure continuity of care and ultimately put physicians back in the driver’s seat of their patients’ treatment plans.”
If enacted, the bill would require MA organizations to notify qualifying providers at least 30 days prior to the first day of each plan year. Reviews for a Gold Card would be limited to once every 12-month period. Gold Card status could be revoked if fewer than 90% of claims were approved for prior authorization.
The secretary of the U.S. Department of Health and Human Services would issue a rule on the use of prior authorization by MA plans to ensure continuity of care for patients in transition or between coverage, and minimize disruption of treatments.
Burgess introduced similar legislation in 2022 and received an endorsement of the American Academy of Family Physians (AAFP).
This year, AAFP noted UnitedHealthcare (UHC) would eliminate almost 20% of existing PAs this summer and create its own national gold card program for physicians. In an April news release, AAFP said, “notably, medications are not included in the services for which PAs will initially be eliminated, so in the short term, the impact on family physicians may not be significant.” But the organization would work with UHC to understand the eligibility requirements and how the program would affect family physicians.