LUGPA Policy Brief:
Prior Authorization Reform and the GOLD Card Act

Dec. 18, 2023 

Prior authorization, a measure to control healthcare costs, requires providers to obtain pre-approval for specific services, products, or medications. Despite its potential cost benefits, prior authorization can introduce administrative complexities, hinder timely treatment, and negatively affect patients' mental health and overall well-being.

LUGPA has been at the forefront of opposing prior authorization policies due to treatment delays and restricted drug access concerns. We support legislation that eliminates barriers to physician-prescribed treatments and prioritizes patients' needs.

The wide use of prior approval by Medicare Advantage providers would appear to create coverage rules that are more restrictive than original Medicare. The high number of prior approval requests is especially concerning regarding Medicare Advantage plans. According to the Medicare Managed Care Manual, Medicare Advantage plan providers must provide coverage rules that are no more restrictive than the original Medicare plan. A 2022 report by the Health and Human Services Office of the Inspector General (OIG) found that Medicare Advantage plans frequently denied care that original Medicare would have covered.

CMS’s Prior Authorization Reform Efforts

In 2022, CMS introduced a new proposed rule to alleviate burdens associated with the prior authorization process. In the Proposed Rule, CMS proposed that all impacted payors implement and maintain an application programming interface (API) to be used by providers to facilitate the prior authorization process.

This electronic system, known as a Fast Healthcare Interoperability Resource (FHIR) Prior Authorization Requirements, Documentation, and Decision (PARDD), would provide information about patients’ prior authorization decisions to help patients better understand their payer’s prior authorization process and how it will affect their care.

The GOLD Card Act:

On July 31, 2023, Congressman Michael C. Burgess, M.D. (R-TX), and Congressman Vicente Gonzalez (D-TX) jointly introduced H.R. 4958, the GOLD Card Act of 2023. This legislative proposal aims to alleviate the burden of prior authorization requirements for qualifying providers under Medicare Advantage plans.

Should the GOLD Card Act be enacted, its provisions will include:

• Exempting providers from mandatory prior authorization if they achieved a prior authorization approval rate of at least 90% in the preceding year for a given Medicare Advantage plan year.
• Requiring Medicare Advantage organizations to notify qualifying providers no later than 30 days before each plan year.
• Limiting Gold Card reviews to a maximum of once every 12 months.
• Inclusion of approvals granted after appeal in the 90% threshold.
• Granting Medicare Advantage plans the authority to revoke a provider's Gold Card status within a plan year under specific conditions, such as insufficient approval rates for submitted claims.
• Granting physicians the ability to appeal Gold Card revocations they believe were unfairly determined.
• Mandating the Secretary of Health and Human Services (HHS) to establish rules for prior authorization use in Medicare Advantage plans to ensure smooth care transitions and minimal disruption to ongoing treatments.

LUGPA’s Advocacy on Prior Authorization:

LUGPA has actively advocated for changes to prior authorization rules, especially regarding Medicare and Medicare Advantage. In March, LUGPA sent a comment letter to the Centers for Medicare and Medicaid Services responding to a proposed rule designed to speed and streamline the prior authorization process and enhance the use of electronic resources by both payors and providers. 

In the letter, which was sent to CMS on March 13, 2023, LUGPA voiced its support for CMS’ goals of streamlining the prior authorization process to reduce provider burden and allow providers to better focus on administering patient care and its efforts to expedite the prior authorization decision-making timeframe and standardize and shorten delays in the process. 

In its letter to CMS, LUGPA presented five recommendations. You can view the complete letter here.

1. Implement the prior authorization API requirements in a manner that minimizes provider burden.
2. Finalize the proposal to reduce timeframes for standard and expedited prior authorization decisions, aiming for a 5-day window for standard requests and 48 hours for expedited requests.
3. Apply the interoperability, prior authorization, and related requirements to beneficiaries of Medicare Fee-for-Service (FFS).
4. Urge CMS to establish an earlier implementation date than January 1, 2026, for the PARDD API requirement.
5. Suggest deferring the implementation of the "Electronic Prior Authorization" objective under the Quality Payment Program's Merit-based Incentive Payment System (MIPS).

The introduction of the GOLD Card Act marks a step toward addressing the challenges posed by prior authorization in healthcare, which will help to reduce provider burdens and ensure patients receive timely and appropriate care.