The healthcare system in the United States faces ongoing challenges with paperwork. One big problem is prior authorization. Prior authorization means doctors must get permission from insurance companies before they can give certain treatments, procedures, or medicines. It started as a way to control costs and make sure care is needed. But now, it often causes delays and extra work for doctors. The Gold Card Act of 2023 tries to reduce this burden, especially for doctors working with Medicare Advantage plans. This article explains the act and how it might affect medical offices and patient care, including how automation and artificial intelligence (AI) could help.
Prior authorization is a rule by many insurance companies. They want to approve some medical services before patients get them. The goal is to keep healthcare costs down and stop unnecessary treatments. But in recent years, prior authorization has increased a lot. Even regular procedures and medicines now often need approval.
According to surveys by the American Medical Association (AMA), doctors in the U.S. handle about 39 prior authorization requests each week. Managing these takes about 13 hours a week per doctor. In some practices, up to 40% of staff time goes to dealing with prior authorizations. This heavy workload causes many doctors to feel burned out. In fact, 89% of doctors say their burnout has gone up because of these requirements.
Prior authorization also affects patient care. The AMA survey found that 25% of doctors saw serious health problems caused by delays or denials in prior authorization. These problems include hospital stays (reported by 23% of doctors) and life-threatening events (noted by 18%). Most denied requests (81.7%) are overturned when appealed, but the waiting still harms patients. This shows the system has big problems and risks.
In 2023 alone, Medicare Advantage insurers got over 50 million prior authorization requests but denied about 3.2 million fully or partly. Many denials and long appeals have made it hard for doctors to focus on patient care because of all the paperwork.
The Gold Card Act of 2023 was introduced by members of both parties in the U.S. House of Representatives. These include Reps. Michael Burgess, MD, and Vicente Gonzalez. The law aims to cut down on the paperwork doctors face from prior authorizations. It targets doctors who usually get most of their requests approved.
Doctors who get at least 90% approval on prior authorization requests in the past year would receive a “gold card.” This card lets them skip prior authorization for at least one year, but only for items and services—drugs are not included. This law is similar to one passed in Texas in 2021. It rewards doctors who usually provide necessary care without overusing services.
The law also has rules to be fair. Exemptions will be taken away only if less than 90% of claims in a 90-day check would have gone through without prior authorization. This check needs at least 10 claims. If a service was denied but waiting on appeal for 30 days, it counts as approved. Doctors can appeal if they think their gold card status is wrongfully removed. People reviewing these cases must be doctors practicing the same specialty in the same state, making sure the review is fair.
The AMA supports this law. They say prior authorization has become one of the biggest problems for doctors. AMA President Jesse M. Ehrenfeld, MD, MPH, pointed out that delays and denials hurt patient care. The AMA sees the Gold Card Act as an important step to reduce paperwork and delays. They also noted that one-third of doctors in their survey reported serious harm to patients from prior authorization delays.
For medical office managers, owners, and IT staff, the Gold Card Act could be a chance to lower paperwork related to prior authorization. Doctors who get the gold card can spend less time getting approvals. This means staff can focus more on patient care, organizing treatments, and managing billing.
Less prior authorization work can also reduce doctor burnout. Burnout is often caused by too much paperwork and rules. When doctors feel less tired, they can take better care of patients. Staff are happier, too, which helps keep the medical office running smoothly and financially healthy.
Also, fewer prior authorization rules could mean patients get care faster. Delays create frustration and can make health problems worse. Medical offices that see many Medicare Advantage patients might find these changes very helpful for running efficiently and improving patient satisfaction.
Along with laws like the Gold Card Act, new technology can help reduce paperwork. Artificial intelligence (AI) is becoming a useful tool to handle prior authorization tasks automatically.
Companies like Simbo AI provide phone systems and AI services that can answer common questions about prior authorization. These tools can take over many tasks like checking the status of requests, logging submissions, and following up with insurers. This lets office staff and doctors spend less time on paperwork.
Automated systems can work with electronic health records (EHR) and billing software to send patient information to insurance companies faster and without errors. This speeds up the approval process and may lower the chance of denials from missing or wrong details.
AI chatbots and virtual assistants can also answer patient questions about their prior authorizations. This saves clinical staff from spending time on phone calls about paperwork. Some AI systems give real-time alerts if more info is needed or if an appeal should be made. This proactive help can reduce delays caused by manual tracking.
IT managers can add AI tools like those from Simbo AI to existing office systems. This can make billing more efficient and help use staff time better. Using AI for repetitive tasks fits a plan to reduce doctor burnout and improve patient care quality.
The Gold Card Act mainly affects Medicare Advantage plans. Offices with many patients on these plans may benefit the most. Medicare Advantage providers get a lot of prior authorization requests. In 2023, over 50 million requests were submitted. The gold card exemption could reduce their workload.
By cutting down the number of requests, the act might lower office expenses tied to processing these approvals. This could also help reduce overall healthcare costs. The law’s rules, including peer reviews and appeals, aim to keep the exemption process fair and focused on good care.
Office managers should know that prior authorization will not disappear completely. To get a gold card, practices will need good records, quick data submissions, and smooth workflows—AI tools can help with this.
The Gold Card Act offers improvements, but some challenges remain.
The Gold Card Act of 2023 tries to solve problems caused by prior authorizations. It aims to reduce paperwork for doctors who care for Medicare Advantage patients by letting those with a high approval rate skip some authorizations. This could lower doctor burnout, make office work smoother, and speed up patient care.
For medical office managers, owners, and IT teams, the law offers chances but also new tasks. They need to watch data carefully, work closely with insurers, and use technology like AI to improve workflows.
Tools like those from Simbo AI can help with phone work and managing prior authorizations. Together with the new law, these technologies can reduce the burden on doctors and staff. This allows healthcare workers to spend more time with patients and less on forms.
Legislation and technology together could help make medical offices in the U.S. work better and reduce paperwork struggles.
Prior authorization is a process by which insurers determine the necessity of medical procedures or medications before they are performed or prescribed, intended to control costs and utilization.
Originally used sparingly, prior authorization has become commonplace, even for routine medications and established treatments, leading to increased administrative burdens.
Physicians face significant time and resource strains, averaging 39 requests per week, with 13 hours spent per week on these processes, contributing to burnout.
Denied requests can lead to adverse patient outcomes, including hospitalizations and life-threatening events, with 25% of physicians reporting serious patient harms.
The AMA advocates for reducing unnecessary prior authorizations, implementing gold-carding programs for frequently approved requests, and eliminating requirements for routine services.
The Gold Card Act proposes exemptions for physicians from Medicare Advantage prior authorization requirements if 90% of their requests have been approved in the past year.
Insurers like UnitedHealthcare and Cigna have announced reductions and exemptions in prior authorization requirements for various services, but many physicians see little change.
Gold-carding programs allow physicians with high approval rates to bypass prior authorization for certain services, thereby streamlining the approval process.
Prior authorization has led to higher overall healthcare resource utilization, with most physicians indicating that it complicates patient care.
The AMA continues to push for reduced volumes of prior authorizations, advocating for gold carding and legislation to improve the process for all stakeholders.
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