UnitedHealthcare releases details on new ‘gold card’ program impacting over 100 radiology CPT codes

The country’s largest commercial health insurer on Sept. 1 revealed details about its new “gold card” program aimed at simplifying prior authorization, with key implications for radiology. 

UnitedHealthcare first launched the initiative in early August, recognizing provider groups that “consistently adhere to evidence-based care guidelines.” Practices that earn the designation will see their prior authorization volume drop, instead following a “simple notification process” for eligible current procedural terminology codes. 

The Minnetonka, Minnesota-based corporation revealed further details on Sunday, releasing the full tally of impacted services. Over 100 imaging CPT codes make the list, among them, CT of the abdomen without contrast, breast MRI and whole-body PET imaging. 

“Prior authorization serves as an important checkpoint to help ensure a service or prescription is a clinically appropriate option. But UnitedHealthcare is taking steps to modernize and streamline the process,” the company said in a Sept. 3 announcement. 

Gold card status will apply across UHC’s commercial, individual exchange, Medicare Advantage and Medicaid plans. To qualify, a provider group must meet three criteria for the past two consecutive years. These include being in-network for at least one line of business, handling a volume of at least 10 of the eligible prior authorizations in each of the last two years, and holding a PA approval rate of 92% during that timeframe. 

UHC emphasized the importance of prior authorization, noting that it can help ensure that beneficiaries receiving coverage for “safe, effective care supported by the most up-to-date clinical guidelines.” The company claimed that PA is required on fewer than 2% of the claims paid by UHC, and fewer than 2% of health plan members experience related denials. UnitedHealthcare also touted prior authorization’s usefulness in taking unnecessary costs out of the system. Waste due to overtreatment and low-value care in the U.S. is between $76 billion and $101 billion annually, UnitedHealthcare noted.  

“The UnitedHealthcare Gold Card program is the next step in continual efforts to modernize the prior authorization process and simplify the healthcare experience for both consumers and providers,” UHC said, also highlighting its elimination last year of PA for 60 radiology CPT codes. 

Healthcare stakeholders took to social media Tuesday to discuss the update. 

“I don’t see any of the top 10 utilized procedures in orthopedics,” wrote Adam Bruggeman, MD, a Texas spine surgeon and chair of the American Academy of Orthopaedic Surgeons’ advocacy council. “No total joint arthroplasty. No knee scope. No shoulder scope. No spine. Not a real gold card but a good PR project. Only win—most MSK imaging is listed.”

“Agreed—it appears the codes are primarily related to OB/GYN, imaging, and various screening services,” responded Tyler Scheid, JD, an attorney and senior healthcare policy analyst at the American Medical Association. “Far from a comprehensive list, and it appears this program will only benefit a few specialties…if it even helps those specialists in the long run…” 

In a separate post, Scheid also criticized UnitedHealthcare for requiring provider groups to have a 92% success rate across all eligible codes rather than specific individual ones. 

A growing number of payers have made attempts to reduce prior authorization requirements amid outcry from providers, patients and politicians. L.A. Care Health Plan announced in August that it is eliminating prior authorization for 50% of radiology codes. About a year ago, Cigna also said it was removing 25% of medical services from its PA list, though none of them were in imaging.

Radiology faces the third heaviest burden from prior authorization in Medicare Advantage, one study found. These burdensome utilization-management tactics can lead to care delays, anxiety and administrative burden for cancer patients, another analysis determined.

The AMA released the results of its latest prior authorization survey in June. Nearly 1 in 4 physicians polled said PA has led to a serious adverse event, and 93% said PA has had a negative impact on clinical outcomes. 

“Payers erect roadblocks and hurdles allegedly designed to save money for the health system and protect precious resources, but when patients and their doctors face care delays—or even give up and abandon necessary care—the result can actually be increased overall costs when worsening health conditions force patients to seek urgent or emergency treatment,” AMA President Bruce A. Scott, MD, wrote in a viewpoint  accompanying the survey results. “Our patients are caught in the middle, twisting in the wind, while physicians fight for them, often with fax machines as our only available weapon.”