The Prior Authorization Disconnect: Can Gold Cards Bridge the Gap?

The cartoon above is something we all have experienced and can relate to.? It shows that in product development, there is often a disconnect between what the customer wants and what developers think the customer wants.

In life, disconnects like this can occur frequently.? Currently, my wife and I are trying to buy a new car, but we are not connected on exactly what that car should be or how much we should pay for it.

Disconnects.

But my personal problems are not the biggest disconnect out there. There is nothing more disconnected then what Payers think about Prior Authorizations compared to what Providers thing about Prior Authorization.

According to the American Medical Association, over 94% of doctors report delays in care due to prior authorization. Furthermore, 78% reported that the PA process sometimes leads to "treatment abandonment."

United Healthcare paints a drastically different picture: "Less than 2% of UnitedHealthcare's members experience a prior authorization denial annually." This stark contrast in perspectives is truly astonishing.

Payers argue that PAs are necessary to identify fraud, waste, and abuse, and to ensure care is given to those who truly need it. However, the implementation of PAs often gives the impression that they're being used as a tool for corporate greed, denying services to those in genuine need.

In light of this wide disconnect, United Healthcare's announcement of their Gold Card Program is intriguing. Despite its misleading name (which sounds more like a credit card offer), the Gold Card Program aims to reduce the number of required prior authorizations for qualifying providers.

To qualify, providers must be in-network with UHC, submit at least 10 PAs a year over two years, and maintain an approval rating of 92% or higher on those PAs. Once qualified, providers can simply "notify" UHC of their recommended treatment plan instead of going through the full PA process.

This program, announced in early September, shows promise. The idea that completing 20 PAs with a 95% success rate could eliminate future paperwork is appealing. However, its effectiveness remains to be seen. As the program rolls out, it will be crucial to gather feedback from providers who experience it firsthand.

If you have any experience with this program in the last month, please share your thoughts and experiences in the comments!