Lawmakers propose ‘gold card’ program that exempts physicians from prior authorization requirements
Bipartisan House lawmakers have proposed launching a program exempting certain physicians from prior authorization requirements spelled out by Medicare Advantage plans.
The Gold Card Act of 2023 would shield doctors for one turn of the calendar, provided they had at least 90% of such PA requests approved in the prior year. It also would require plans to notify physicians if they qualify for the program no later than 30 days before the start of the next plan year.
Insurers typically use prior authorization to control utilization of healthcare services, but the practice is prone to abuse. Patients recently sued Cigna, alleging its program shirks the law by denying claims in bulk. Radiology faces the heaviest burden from prior authorization in Medicare Advantage, behind only radiation oncology and cardiology, a recent JAMA Health Forum analysis found.
“This commonsense bill will pass at the federal level what many states, including Texas, have already enacted,” Rep. Vicente Gonzalez, D-Texas, who sponsored the bill alongside Rep. Michael Burgess, MD, R-Texas, said July 31. “Bureaucratic red tape should not hinder patients’ ability to receive attention or our medical professionals’ ability to perform preventative or even life-saving care.”
In addition, the Gold Card Act would allow Medicare Advantage plans to revoke providers’ premier status if they fall below the 90% threshold. Physicians would have the ability to appeal these revocations if they believe insurers reached them erroneously. It also would require the HHS secretary to issue a rule on the use of PA by Medicare Advantage carriers “to ensure continuity of care” for those transitioning between plans.
The bill has drawn support from provider groups including the Texas Medical Association and national associations representing orthopedic surgeons, emergency physicians, dermatologists, neurological surgeons and ophthalmologists. The legislation does not specifically call out imaging or other services. The Medical Group Management Association said Monday that radiologists, along with others who order imaging, stand to benefit from a gold card program like the one outlined.
“Year after year, medical practices identify prior authorization requirements as the most challenging and burdensome obstacle to delivering high-quality patient care,” Anders Gilberg, senior VP of government affairs for the MGMA, which represents more than 15,000 physician groups across radiology and other specialties, said in writing. MGMA supports the Gold Card Act of 2023 as “a critical step toward much-needed reform,” he added, saying the legislation would allow physician practices to “focus resources on patient care.”
Burgess previously proposed the same legislation in June 2022, but it failed to find passage.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.