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Prior Authorization/Gold Carding

What is it?

In an effort to contain health care costs, most health insurers require a physician to obtain “prior authorization” before prescribing certain medications and health services. Most medical practices contract with multiple insurance companies, each with its own approval process.

What’s more, each of those companies frequently utilizes a different form for each test, procedure, service, or medication requested. This administrative burden distracts from the provision of high-quality care and costs health systems close to a billion dollars annually, according to peer-reviewed reports.

State legislatures are now considering “gold carding” legislation to help streamline the prior authorization process. This new policy exempts high-performing physicians from prior authorization requirements if they have a prior authorization request approval rate percentage that meets the minimum threshold established in the law (ex. 90%). However, Texas is the only state to date that enacted this type of legislation (law passed in 2021), and it is still too new to know if it will be effective.

Why is it important?

Prior authorizations create access issues and severe delays in receiving the right treatment at the right time. This delay can cause increased hospitalizations and loss of drug adherence.

What is CSRO doing about it?

The Coalition of State Rheumatology Organizations (CSRO) supports a prior authorization policy that:

  • Requires prior authorization requests to use a single form, but no more than two pages in length.
  • Forms must be available electronically for both access and submission.
  • Requests are deemed approved if no response is received within 48 hours.

With the passage of the gold card law in Texas, which was issued to qualifying physicians in October of 2022, CSRO is actively collecting data to evaluate the effectiveness of this approach.

Additionally, CSRO gives its full support to the American Medical Association’s (AMA) creation of the 21 principles to reform prior-authorization requirements, which was established in 2017 by a collective of provider and patient associations, including the CSRO.

What can YOU do about it?

Visit our Legislative Map Tool to read about current prior authorization laws or legislation in your state. You can send letters in support of pending legislation and find educational materials.

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