Judicial scales with someone signing legislation papers in the background out of focus

Texas law mirrors similar legislation in several other states

Texas legislators and those in other states have pulled a page out of the American Express playbook where a gold card has its “privileges” and have applied it to prior authorizations.

The Texas “gold card bill” (HB 3459) allows physicians with a prior authorization approval rate of 90% or more over six months on certain services to be exempt from a prior authorization for those services.  Providers and physicians do not apply for the cards. Instead, health plans run an evaluation to see if the providers meet the 90 percent threshold. The plans are then responsible for notifying the provider of whether they qualify. After each six-month review period, new providers or new services for existing providers are added or removed based on the results.

The law went into effect on October 1st and was one of several legislative topics discussed at the Texas Covered Healthcare Conference and Expo, attended by NantHealth’s sales and marketing staff.

Payers Say the Gold Carding Legislation is Unnecessary

Physicians and other providers applaud the bill, saying a state gold carding bill is necessary as the first step towards a more consistent pre-authorization policy nationwide.

“We’re thrilled that there is a law now in Texas that does this,” said Anders Gilberg, Senior Vice President of Government Affairs for the Medical Group Management Association (MGMA), in a recent article in MedPage Today. “Ultimately, there needs to be a more standardized process across all health plans across the country.”

But health insurance companies argue that the law is unnecessary because providers and payers are already working together to reduce the burden of prior authorizations, including greater use of electronic pre-authorization approvals.

“Providers and health insurance providers are already working together to improve the prior authorization process, including greater use of electronic prior auth, as well as gold carding,” said James Swann, Senior Manager of Communications at AHIP, in a MedPage Today article.

Health Plans Have Seen Mixed Success with Gold Carding

In a recent survey by AHIP, 69% of the plans using gold carding programs showed positive outcomes from them, such as reduced administrative burden and improved provider satisfaction. But 73% of respondents also indicated some negative outcomes, such as difficulty administering the program, higher costs, and reduced quality of care for patients. Some plans said those were the same reasons why they discontinued the program.

Texas is Not The Only State Implementing Gold Card Legislation

Other states have signed or are considering similar laws. For example, Michigan has enacted the Health Can’t Wait Act, which shortens the time payers have to consider prior authorization requests and requires payers to provide more information to the public and providers regarding the prior authorization process.

In Pennsylvania, Governor Tom Wolf signed a bill requiring insurers to provide timely approval for non-urgent and emergency healthcare services to physicians before treatment plans or services are administered. The bill also creates a process for appeals determinations. If an insurer questions the necessity of a service, the bill calls for a peer review by a physician from the specialty in question. It also creates an electronic portal with all prior authorizations.

Under Vermont House Bill 960, carriers must implement a pilot program that automatically exempts from or streamlines certain prior authorization requirements for a subset of participating healthcare providers. To qualify, a provider must have received 100 percent approval of their prior authorization or pre-certification requests submitted within six months for a procedure they performed an average of 30 times per year.

Prior authorization is a requirement that a provider (such as a physician or hospital) must obtain approval from a health insurance plan before prescribing a specific medication or performing a particular medical procedure. This determines whether or not a procedure or drug will be paid for in whole or in part.

Interested in learning more? Check out The Ultimate Guide to Prior Authorizations to discover everything payers need to know about simplifying the prior authorization process.

NantHealth’s NaviNet Open technology platform enables real-time exchange of HIPAA-compliant prior authorization, submission requests, and inquiries between health plans and providers. In addition, Eviti Connect, NantHealth’s evidence-based treatment validation platform, reduces the administrative time involved in obtaining and providing authorizations surrounding oncology and autoimmune disorders.

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