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ACP is monitoring implementation of the UnitedHealthcare Gold Card Program, which allows eligible physician practices to bypass need for prior authorization of certain services

Oct. 11, 2024 (ACP) -- UnitedHealthcare launched a new nationwide program this month that eliminates the need for physician practices meeting certain criteria to submit prior authorization requests for certain medical, behavioral and mental health services.

The Gold Card Program will be offered across its commercial, individual exchange and Medicare Advantage and Medicaid business lines. It will be modified, when necessary, to meet state requirements. To qualify, practices must demonstrate a prior authorization approval rate of 92 percent or higher and meet a minimum volume of at least 10 eligible prior authorizations for two consecutive years.

“Prior authorization is one of the most onerous administrative burdens physicians face, forcing them to divert significant amounts of time and focus away from patient care,” said Dejaih Johnson, ACP manager of regulatory affairs. “As part of ACP's Patients Before Paperwork Initiative, we have advocated for state and federal reform. Prior authorizations often lead to increased use of health care resources, resulting in waste rather than the cost savings claimed by insurers. Prior authorization requirements have also been found to harm patient care, causing delays or outright inappropriate denials.”

UnitedHealthcare has released a comprehensive list of Gold Card-eligible CPT codes. “Many of the codes are related to surgery and imaging, but internal medicine physicians are encouraged to review the complete list of codes to assess the impact on their practice,” Johnson said.

ACP will monitor the new program. “To the extent that the program actually reduces prior authorization barriers to care and is not itself administratively difficult to implement, it is a step in the right direction,” Johnson said.

Still, “it is a little bit of a wait-and-see,” she noted, and ACP is concerned about the limited role that demonstrating better health outcomes plays in the program. “Prior authorization reforms must simultaneously reduce administrative burden and improve quality of care. Gold card programs must put physicians, not insurers, as the arbiter of what is best for a patient based on clinical outcomes,” she said.

ACP continues to lobby Congress to address national prior authorization reforms. Members are encouraged to act through the ACP Legislative Action Center and reach out to their legislators regarding the Improving Seniors' Timely Access to Care Act, which would protect patients from unnecessary delays in care and reduce the administrative burden on physicians by streamlining the prior authorization approval processes in Medicare Advantage.

“This legislation passed in the House in the last Congress but failed to advance in the Senate. Most Senate members supported it, but there were concerns due to the estimated cost of implementing the bill,” Johnson said. “Fortunately, estimates on the cost of this bill have been reduced significantly. We now need members' help to push it over the finish line and to focus our attention on policies that cut through bureaucratic red tape and improve the nation's health.”

To learn more about ACP efforts to reform prior authorization and to contact members of Congress to urge them to pass the bill, members can visit the online toolkit, “Addressing the Administrative Burden of Prior Authorization,” which includes information about ACP policy positions, its advocacy efforts, and how members can take action to ensure their voice is heard.

“Members can use the toolkit to educate themselves about the policy landscape and take action to help ACP advocate for reforms both at the federal level and in their states,” Johnson said. “We also have a two-part recorded webinar series where we collaborated with Medicine Forward, a group that unites clinicians, patients, and change leaders to restore the patient-physician relationship as the heart of medicine, reduce administrative burdens, and advance solutions for prior authorization.”

Back to the October 11, 2024 issue of ACP Advocate