The traditional prior authorization process has been a valuable tool for health insurance companies to manage cost and utilization, but it also represents a drain on staff time and resources for providers and plays a large part in delayed care and provider/patient dissatisfaction.

Both state and federal governments have started to respond to the issue, proposing or passing regulations intended to reduce administrative burden, improve patient access, and require consideration of a providers’ historical care decisions in the prior auth process. This last requirement represents a trend emerging in the more progressive legislation and rule making in recent years. In many cases, this manifests as a mandatory push to allow certain providers with demonstrated quality performance to receive exemption from prior authorization requirements. In this new era of quality-based exemption, traditional programs like physician gold carding won’t suffice, and risk driving up costs for health plans faced with these new emerging mandates.

A Push for Change

While using legislation and rulemaking to mandate gold carding-like programs is certainly a recent trend, the concept and practice of gold carding is not. Almost every payer’s prior authorization process already includes some level of gold carding built in. However, the details and guidelines for eligibility tend to be arbitrary and opaque and a lack of consistency across payers continues to add to provider and patient frustration.

Under a new Texas law (Texas H.B. No. 3459) that took effect in September 2021, physicians who have at least a 90% prior authorization approval rate over a period of six months will be eligible for exemption from certain prior authorization required services. But, because this law does not affect all health plans or lines of business, Texas health insurers have a tremendous task in front of them to find a way to segment their member populations and become compliant, while providers will need to understand the nuances of what category their patient care falls into, often only receiving exemption from a handful of the 4,000+ medical services typically requiring prior authorization. Plus, with legacy systems, lacking provider performance data and limited internal resources, health plans are looking at substantial costs and complexities to implement, especially if they don’t already have strong data and analytics capabilities in place.

While the legislation attempts to set a foundation for change for the provider and patient experience, it also leaves plenty of opportunity to envision how we can push utilization management forward as not simply a tool for controlling cost, but an opportunity to create greater collaboration between health plans, providers, and patients. So, is there a better way?

A “Green Light” Approach

At Cohere Health, we’re building the next generation of gold carding, deploying a data-driven, dynamic approach to green light providers. Green lighting takes foundational concepts of gold carding, which reduces the burden on providers with high quality and value, and layers on data driven intelligence, such as the clinical appropriateness of the provider’s current and past ordering behaviors, at the time of service ordering. Using industry and peer benchmarking along with evidence-based guidelines, green lighting leverages ongoing and real-time provider evaluations, instead of a manual “moment in time” historic view that a health plan would review only at the time of negotiation with the provider.

Cohere’s green lighting approach also takes into consideration a provider’s longitudinal impact on the patient’s care journey, from end to end, providing a more comprehensive assessment of the provider’s quality and value of care. With this real-time analytics, health plans can then incentivize high performing providers through fast approval with minimal data submission. Furthermore, the real-time analytics allow health plans to customize the scope of green lighting to be as large as all services or as detailed as selected procedures and can also green light an entire practice or individual high performing providers. What once would have been a stagnant list, with little chance of review or change, is now dynamic based on ongoing provider performance making it easier to identify improvements, gaps over time and actionable insights

While this process makes it easier to identify top performers, the analytics behind green lighting also allows health plans to tap into another potential opportunity – to focus on providers who are not performing to appropriate levels and work with them to reinforce best practices. UM systems and processes designed around greater collaboration and transparency can lead to less burden on both the providers and the plan. Health plans can proactively and transparently communicate performance metrics, including a comparison vs their peers to help drive performance and long term behavior changes resulting in a better care journey for the patient and green lighting opportunities for improved providers.

What’s Next?

Texas may have been the first to pass and implement this regulation, but other states and the Federal government continue to take similar action. For example, The Improving Seniors’ Timely Access to Care Act, which would affect seniors under Medicare Advantage plans, continues to gain bipartisan support within the US House of Representatives and Senate. In addition, state governments, including Pennsylvania, Georgia, Ohio and New York, continue to push for additional reforms. With this influx of regulation and change, it’s going to take new ways of thinking, provider partnerships and evidence-based analytics for health plans to continue to stay on top of utilization management and help reduce the burden of an already complex process.