Gold carding programs are programs that eliminate or reduce prior authorization requirements for providers whose requests for prior authorization have consistently been approved and/or who have met other evidence-based criteria.

In its recently published proposed rules for Medicare Advantage plans for the 2024 contract year, CMS encouraged Medicare Advantage Plans to implement gold carding programs, stating:

It is appropriate to reiterate in this rule that we believe the use of gold-carding programs could help alleviate the burden associated with prior authorization and that such programs could facilitate more efficient and timely delivery of health care services to enrollees. We encourage MA plans to adopt gold-carding programs that would allow providers to be exempt from prior authorization and provide more streamlined medical necessity review processes for providers who have demonstrated compliance with plan requirements.

In its comments to CMS regarding the proposed rules, the American Medical Association supported CMS’s recommendation that Medicare Advantage plans implement gold-carding programs and urged CMS to go further and require Medicare Advantage plans to do so:

We appreciate CMS’s acknowledgement of the enormous resource drain PA [Prior Authorization] presents for physicians and their practices…AMA survey data quantify the time and resources that physicians and their staff spend on an ever-growing PA workload, with 88 percent of physicians describing their PA burden as high or extremely high. This burden translates into less clinical time with patients and contributes to an exhausted, burned-out, and overwhelmed workforce….

For these reasons, we are pleased to see CMS encouraging MA plans to implement gold-carding programs to allow physicians to be exempt from PAs when they have a track record of high approval rates….We believe that MA plans are particularly well suited to implement gold-carding programs, especially given the consistency in coverage criteria in this proposed rule, and we encourage CMS to establish a requirement on plans to develop such programs.

(emphasis in the original)

The proposed rules are entitled CMS 4201-P, Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Program.  The AMA’s comments are linked here.




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