The Gold Combing Program is designed to improve prior authorization. Are they working?

Ask providers what causes tensions caused by relationships with insurance companies, many will point to prior authorization, believing that the practice can create administrative burdens and delay patient care.

To improve prior authorization, many insurance companies and states have introduced gold programs in which providers with reliable records approved for prior authorization exempt some prior authorization requirements. This includes Texas, which can exempt providers from requirements if there is a law that will authorize certain procedures if the final approval rate for these requests is 90% or higher.

But are these programs valid? So far, the Texas Medical Association (TMA) has been disappointed with Texas gold medal law.

Ezequiel “Zeke” Silva III, Chairman of the TMA Legislative Council, said that given the frequency of the previous authorization requests finally approved, you would think that we will have quite a few doctors. “It’s a pity that the final data we’ve seen about the number or percentage of physicians reaching that status is 3%. ”

Despite some providers’ disappointment, efforts are still being made to improve the gold combing. In Texas, for example, this means further improvement of the law. Some plans are developing new plans to help providers reach gold card status. But others believe that the previous authorization is a flawed tool developed for naturally broken systems. At least one health plan CEO said he wanted to focus on value-based care.

Problems with the Golden Habits Procedure

When Texas’s Golden Card Law was originally enacted in 2021, Silva and TMA had “conspicuous optimism” and hoped it would make a difference to the previous authorization.

However, in the years since its implementation, the law was insufficient. One problem is that there is little transparency and data to understand how gold cards work.

“When it passes, it is the responsibility of the health plan to determine the exemption card, notify the doctor and manage accordingly. “There is no claim process against the doctor.” This is purely according to the management plan. ”

According to Silva, few doctors actually receive gold cards, only 3%. Given that it is Starting in 2022, this highlights the lack of robustness of existing laws.

There also seems to be some degree of inconsistency in the way the doctors are given gold cards. Silva gives two examples of his doctor who spoke to Texas about gold medals.

“I’ve talked to an orthopedic doctor and I know he does have a gold card and one of the comments he made is that he didn’t pursue it according to the health plan,” he said. “He didn’t call them.

According to Silva, the latter’s doctors tried to connect with several health plans to determine their status and eventually give up.

Another problem is that the law only applies to state-regulated programs, not government payers like Medicare and Medicaid, nor to ERISA programs. So, this only affects a small percentage of Texas’ health plans.

The Texas Medical Association’s problems with gold combing reflect what a supplier across the country sees. Cohere Health is a health technology company dedicated to improving previously authorized health technology. The company’s chief product officer Matt Parker said the idea of ​​gold cards is not bad, but it doesn’t have to be solved in practice.

Like Silva, he said the plan lacks transparency in how it is designed, and getting into the Gold Card program is actually very challenging for providers. He noted that in general, there is little clear clarity on how to obtain a gold card status, and the number of participating providers is small.

“The problem of gold combing is indeed over [that] This is not a super sophisticated, flexible or transparent way to identify providers of proper care that always prescribe. ” Parker said.

However, the challenge is not necessarily just about the provider. He added that there are instances of peak utilization and spending after the provider reaches the gold card. In other words, after the provider reaches the gold card status, it is almost considered a license to order more tests or perform more programs.

Due to these challenges facing gold combing and prior authorization, Cohere Health recently launched a new product called Cohere Align. Products analyze providers’ behavior and group them into performance-based accomplices, so health plans can create targeted interventions for these peers. The cohorts with high performance had fewer prior authorization requirements, while cohorts with lower performance received more education and coaching, which could improve clinical outcomes. Cohere alignment also keeps track of performance.

There are some successful gold combing methods. Pennsylvania-based insurance company Highmark has a program that provides gold for practice and physicians when it comes to approval levels for specified CPT codes and patterns such as CT scans, MRIS, or nasal endoscopy. This can be used in commercial, affordable care bills and Medicare Advantage programs.

Insurers automatically register providers twice a year when eligibility occurs, and Highmark sends notifications to providers who have joined the program. Then, once the provider wins the gold medal, Highmark tracks the provider’s ordering trends and conducts a random review of utilization. With the gold card, the provider simply needs to send pre-order to arrange the service and grant approval immediately.

“The concept of gold combing is very simple, basically about sharing the actual data that starts moving the needle so you can get as upstream as possible,” Dr. Tony Farah, executive vice president and chief medical and clinical transformation officer at Highmark Health, said in an interview. He added that this is something that other payers can easily replicate.

Highmark operates in Pennsylvania, Delaware, New York and West Virginia. West Virginia has a gold medal authorization, which is high marks that meet, while other states do not.

The insurance company also offers a program called “Proactive Gold”. Through this, Highmark works directly with clinicians and provides support from concierge nurses. Highmark provides real-time feedback as well as real-time manual and virtual coaching to help physicians practice submit accurate and clinically appropriate requests. Once the provider has completed an active gold card habit plan, they get a golden grooming.

According to data shared with Medcity News, the gold medal clinician who paid through highlights took less than three minutes to submit pre-release and get approval. Currently, over 23,000 clinicians are gold medals, or 11% of the insurer networks. There are also 1,600 active gold clinicians in its network.

There is at least one doctor in the Highmark network – Dr. Timothy Sauber, an orthopedic surgeon at the Allegheny Health Network Institute – who is very happy with the Gold Card program. His MRI, CT, nuclear medicine, total knees and total hips are gold medals.

However, he pointed out that he wanted to get to the point where he eliminated the sending pre-requisite. Still, the process is “very minimal and simple”, he said.

“You are still spending a small amount of time executing the authorization, but you don’t have to say, ‘We have to contact you to see if there will be approval.’ You will never have the risk of denial to stand out in the authorization process.”

Changes required

The Texas Medical Association is working with the state to improve its gold medal law. One change the organization hopes to see is maintaining a database of prior authorization, denial, appeal, third-party review and other information for the Texas Department of Insurance. According to Silva, this will help inform the providers how they get the gold card status.

The organization also strives to exempt certain conditions from prior authorization. At the last legislative meeting (2023), autoimmune conditions were exempt from prior authorization. At this session, TMA is studying other conditions or services, such as chronic conditions or preventive screening.

“We think it’s a very focused focus on patience and patience, and we think it will resonate,” Silva said.

Meanwhile, another industry executive believes that a broader conversation is needed about the previous authorization, which is beyond the gold medal. Dr. Sachin Jain, CEO of Scan Group and Scan Health Plan, said the gold medal was “very easy to talk about, but hard to execute.”

“If you treat different providers in the network differently, I think it creates friction through your network,” he said. “Ultimately, there is already a lot of friction in the network, so what we have to do is minimize that friction.”

Scans without gold medal plans, and actually delegates the risks of the group of providers they partner with to them so that they can make their own prior authorization. He believes that accelerating value-based care will actually greatly improve tensions in previous authorizations.

“If we really authorize primary care to get primary care, we will have a very different health system, if we really invest more in the management of chronic diseases for outpatients. … Patients will need fewer procedures. Because they will be healthier. Unfortunately, most people don’t have access to primary care physicians these days. These days, when they do, when they lose approval, deny, deny, deny, deny, deny, deny, deny, deny, deny, deny.

Photo: Piotrekswat, Getty Images