“Gold Card” Approach to Prior Authorization Introduced in Congress

What are the news: A bipartisan bill introduced in the U.S. House of Representatives would help minimize the burdens associated with prior authorization in Medicare Advantage plans.

The “Getting Over Long Delays in Care as Required by Doctors Act of 2022” is sponsored by Texas Representatives Michael Burgess, MD, a Republican, and Vicente Gonzalez, a Democrat.

The bill, called the “GOLD CARD Act” for short, exempts physicians from Medicare Advantage plan pre-approval requirements as long as 90% of physician applications have been approved in the previous 12 months.

The “gold cards” issued by the Medicare Advantage plan would only apply to items and services – excluding prescription drugs – and would remain in effect for at least one year. The legislation is based on a similar law enacted in Texas that went into effect in 2021.

Fixing prior authorization is a critical part of the AMA’s stimulus package for American physicians. You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And WADA is ready.

Prior authorization is overused and existing processes present significant administrative and clinical challenges. Learn how the AMA is tackling prior authorization with research, practice, and reform resources.

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Why it matters: “Almost daily, prior authorization frustrates physicians by complicating patient care with unnecessary administrative hassle,” outgoing AMA President Gerald E. Harmon, MD, said in a statement. press release issued by Representatives Burgess and Gonzalez in June. “This bill incorporates common sense reforms that will benefit Medicare Advantage patients and reduce physician burnout, including exempting physicians with high pre-authorization approval rates from these health management requirements. ‘use.

“We went to medical school to provide the best possible care to our patients, not to waste time ticking boxes,” Dr. Harmon said. “Not only does this bill help streamline prior authorization, but the ‘GOLD CARD Act’ provides ample opportunities for physicians to appeal attempts by Medicare Advantage plans to override this exemption.”

The AMA commended Texas congressmen “for introducing this bipartisan bill that will lead to higher quality care, better health care outcomes, and improved physician and patient satisfaction.” , Dr. Harmon said.

The AMA’s latest Physician Prior Authorization Survey (PDF) illustrates the negative impact of prior authorization on physicians and patients. More than a third (34%) of responding physicians said that prior authorization resulted in a serious adverse event, such as hospitalization, disability, permanent bodily harm or death, for a patient in their care.

The 2021 AMA survey also highlights that 93% of physicians reported delays in care associated with prior authorization, and 82% said these requirements can at least sometimes lead patients to abandon treatments.

Find out why prior authorization is bad for patients and bad for business.

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Learn more: Following direct advocacy by the AMA, the “GOLD CARD Act”—HR 7995— also establishes numerous processes to ensure that Medicare Advantage plans cannot improperly revoke this exception to prior authorization practices.

Although it is permitted under the bill to override the exemption, Medicare Advantage plans must demonstrate that less than 90% of claims submitted during a 90-day plan period would not have received relief. ‘preliminary authorisation. This 90-day look-back period should be extended until at least 10 claims are finally provided. Services initially declined and pending appeal for at least 30 days should be considered “approved” against 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 reviewing potential Gold Card cancellation must be actively engaged in the practice of medicine in the same or similar specialty as the physician being reviewed, have knowledge of the service specific in question and possess an unrestricted license in the same state as the providing physician. Physicians who hold the gold card can also appeal any attempt to overturn the exemption.

Learn more about how Texas’ new Physician Gold Card law will reduce pre-approval times.

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