Dive Brief:
- Centene revealed on Tuesday its plans to introduce a gold card program next month as part of the larger efforts within the healthcare sector to reform the prior authorization system.
- This initiative will exempt top-performing providers from the usual prior authorization requirements for certain medical services, procedures, or prescriptions.
- According to the insurer, over 160,000 providers across the country will be able to access this program based on their approval history, the quality of their documentation, and their adherence to medical policies and regulations.
Dive Insight:
The initiative, known as the National Performance-Based Gold Card Program, will initially be limited to specific outpatient services. Centene anticipates gradually broadening the range of services and the number of providers eligible for the program.
Providers who qualify will need to give a pre-notification before providing services but won’t have to wait for the insurer’s approval, as per the announcement.
Healthcare professionals have praised gold card programs for reducing significant administrative hurdles in the prior authorization process. These programs also facilitate quicker patient care, avoiding long delays in obtaining insurance approvals.
Traditionally, insurers have been hesitant to voluntarily implement such programs, concerned they might result in overutilization of costly, unnecessary services.
Nonetheless, approximately a dozen states have enacted laws requiring insurers to adopt similar programs to help reduce delays in patient care and address issues of physician burnout. Additionally, states like New York are contemplating similar legislative measures.
The issue of prior authorization has also drawn federal attention, with the previous administration securing promises from major insurers last year to diminish these processes. In April, insurers announced an 11% reduction in prior authorizations thus far.
Some health insurers are responding to the trend by establishing their own gold card initiatives. For instance, Humana launched a program this year that eliminates prior authorization requirements for certain services for eligible providers.
UnitedHealthcare also expanded its program earlier this month, increasing the number of provider groups eligible for expedited prior authorizations by 80% since it began two years ago.
Still, provider organizations and patients are vocal in their opposition to prior authorizations. Providers argue that reforms haven’t significantly eased their prior authorization burdens, while patients remain stuck waiting for approvals to access necessary care.
Provider groups persist in urging insurers to adopt gold card programs, which were not explicitly included in the commitments to simplify prior authorizations.
