Prior authorization gold cards might need a new prescription

Move over, Amex. There’s a new gold card in town.

Payers including UnitedHealthcare and Health Care Service Corporation (HCSC) and states like Arkansas and Texas have created “gold card” requirements to cut down on prior authorization wait times for vetted providers.

United’s program, for instance, gives a gold card to “provider groups who consistently adhere to evidence-based care guidelines” and have prior authorization approval rates of 92% or higher over at least two years.

Unlike a credit card, however, you can’t tuck prior authorization gold cards into your wallet. This designation just means these providers are allowed to give advance notification to United for eligible procedure codes rather than going through the full prior-authorization process, which requires clinical information and can have lengthy wait times.

The stated goal is to make things easier for providers. In the American Medical Association’s annual 2023 prior authorization physician survey, physicians said prior authorization takes an average of 12 hours a week and 93% said it at one point delayed patient care.

Unmet potential

But despite their promise, these programs haven’t had a big impact yet.

“It’s a partial solution,” Kaye Pestaina, director and VP for KFF’s program on patient and consumer protection, told Healthcare Brew.

Pestaina said there are other issues gold cards don’t address. For instance, providers say some insurance companies are requiring prior authorization for an increasing number of procedures, and gold cards don’t reduce that.

In addition, not many providers appear to be qualifying for gold cards under the current requirements.

United spokesperson Matthew Rodriguez told Healthcare Brew providers aren’t eligible for the company’s gold card program, launched in September 2024, unless they submit more than 10 prior-authorization requests each year for the past two years.

Of those who met that threshold, about 20% qualified, meaning they had at least a 92% approval rate across all gold-card eligible medical codes, he added.

“If providers are not being exempt from having the prior auth in large numbers, it’s not clear how much it’s going to help in the short term,” Pestaina said.

High qualifications

In Texas, meanwhile, only 3% of providers have qualified for the state’s gold card as of December 2024, according to the Texas Department of Insurance. The policy took effect in October 2022.

Providers have to have issued at least five preauthorization requests for a specific service during a six-month evaluation period in order to even be considered. If at least 90% of those requests were approved, providers are then exempt from prior authorization for that service from that health plan.

Sounds simple, but it’s a “somewhat difficult” threshold to meet, Ezequiel Silva III, chair of the Texas Medical Association Council on Legislation, told the American Medical Association in an October 2024 interview.

Some health plans have also been resistant to implement the program, he said.

A 2022 survey from political advocacy and trade association America’s Health Insurance Plans found 69% of the 26 plans reported positive outcomes from gold cards, like reduced administrative burden and improved provider satisfaction. But 73% said they had negative outcomes, such as the programs were difficult to implement and led to higher costs. 

Pestaina also added that gold cards don’t necessarily help the patient because patients can’t see which providers are gold carded.

“For the consumer, I’m out of luck if I’m with a provider who just happens to see more patients whose prior auth was denied—whether appropriately or not appropriately,” Pestaina said.