Gold Carding Has Mixed Effects on Streamlining Prior Authorization Processes

While more plans have turned to gold carding as a method for streamlining prior authorization for medical services in the past three years, the approach has a mixed success rate, according to an AHIP survey.

The researchers conducted the survey online from February to April 2022. Twenty-six commercial health plans representing 122 million enrollees responded to the survey.

The survey is based on the 2018 Consensus Statement, a document signed by six major trade organizations for the health insurance, pharmaceutical, and healthcare provider industries that commits to improving prior authorization. The Consensus Statement’s signers agreed to use it selectively, alter reviews and volume, promote transparency and communication between stakeholders, prioritize continuity of care, and pursue automation.

The AHIP survey followed up on these areas for improvement to see whether the commitment successfully changed prior authorization processes for the better.

Most health plans said that they were streamlining the prior authorization process—96 percent of plans said that they had streamlined the prescription medication prior authorization process and 92 percent had streamlined their medical services prior authorizations.

Streamlining prior authorization can take a variety of forms.

Most health plans said that they used electronic prior authorization to streamline their medical services (88 percent) and their prescription medications (75 percent). The two biggest barriers to electronic prior authorization adoption among providers were not using EHRs that were enabled for electronic prior authorizations and the cost or burden of buying or upgrading their EHRs to accommodate electronic prior authorizations.

Many providers continue to submit prior authorizations manually—60 percent of medical services prior authorizations and 39 percent of prescription prior authorizations were manually submitted.

However, apart from using electronic prior authorization, plans’ approaches differed widely for their prescription medications compared to their medical services.

For medical services, nearly six in ten plans streamlined prior authorization processes by using “gold carding”—adjusting prior authorization requirements for providers with a record of high-quality care.

Gold carding increased in popularity in 2022, compared to 2019. Nearly six in ten plans used gold carding for medical services in 2022 (58 percent), compared to slightly less than a third in 2019 (32 percent). A little over a fifth of health plans used this method for prescription medication prior authorizations in 2022 (21 percent), whereas only nine percent had leveraged this approach in 2019.

Gold carding was most frequently employed for high-tech imaging services (44 percent). However, 19 percent of plans used it for orthopedic, elective inpatient, and cardiology services as well.

Health plans often looked for three qualities of a provider to determine eligibility for gold carding: low prior authorization denial rates, minimal prior authorization requests, and risk-based contract participation. Two-thirds of plans reviewed eligibility either annually or semi-annually.

However, despite increased use, payers had a wide range of perspectives on the approach.

The highest shares of respondents found that the approach successfully reduced provider burdens and improved provider satisfaction (46 percent for each). Almost a quarter said that patient safety was stable or saw improvement (23 percent).

But a third of the respondents found that the approach was challenging to put into effect due to administrative difficulties. A fifth found that gold carding reduced quality and the same share found that the approach resulted in higher spending but no discernible quality increases.

As a result, some health plans discontinued their gold carding programs. Three-quarters of those who discontinued indicated that the approach was too challenging administratively. Half of the respondents found that quality of care or patient safety dropped and a quarter pointed to higher costs without return on investment as the reason for discontinuing.