18-07-2025
'Gold Card' Programs Offer Limited Prior Auth Relief
This transcript has been edited for clarity.
Gold card programs were introduced as a potential solution to streamline the prior authorization process, allowing physicians with consistently approved requests to bypass certain insurance requirements.
However, the results have been disappointing. In Texas, an early adopter of this approach, only 3% of healthcare providers qualified for gold card status.
The impact on healthcare delivery is significant; physicians and their staff spend approximately 13 hours weekly on prior authorization documentation, resulting in delayed patient care.
Under current requirements, healthcare providers must submit at least five requests for a specific health service over a year, with a 90% approval rate to achieve gold card status.
While the concept makes intuitive sense, it raises concerns about equity. Larger medical groups with more resources may navigate the process more successfully than smaller private practices.
A recent study of Medicare Advantage insurers revealed limited consensus on which treatments require prior authorization. Only 12% of Medicare spending would have required prior authorization across all studied insurers.
The impact extends to patients, too, with two thirds of cancer patients becoming personally involved in authorization processes, leading to decreased trust in the healthcare system overall.
