On September 1st, UnitedHealthcare (UHC) released details about its national gold card program.
As a reminder, practices are eligible if they are in-network with one of UHC’s health plans, complete at least 10 prior authorizations annually in the two year review window (4/1/22 – 3/31/24), and had an approval rate of at least 92% across all gold card-eligible codes.
However, ACG is seeking clarity from UHC on whether gold card status will be service- or code-specific (as it is for other programs) or granted en masse for all eligible codes.
Leaders from ACG’s Prior Authorization Task Force have reviewed the code list and summarized those most likely to impact your GI practice. Although GI procedures were not included, many codes for GI imaging-related studies were selected.
ACG has also issued the following statement:
“Gold card programs were initially hailed as a pathway to improving quality of care while reducing administrative burden typical of utilization management requirements. However, as implemented, these programs are poised to be nothing more than the next generation of arduous, failed prior authorization protocols – especially because eligibility is assessed by past prior authorization approval rates, not by demonstrating better health outcomes.
On September 1st, UnitedHealthcare published the full code list of services that are eligible for gold card exemptions. Although GI procedures were not included, many codes for GI imaging-related studies were selected. To help ACG members evaluate their decision to participate, we have created a summary document of these codes that are expected to impact GI. ACG is unsure of the actual burden reduction, as an ‘advanced notification’ is still required. Individual practices must ultimately decide what is best for their patients and staff; if your practice frequently uses these imaging codes, participation in this program might be beneficial for your UHC patient population.
ACG remains skeptical about the benefits of gold card programs because they rely on the same faulty logic as their predecessors: that insurers, not physicians, should be the arbiter of what is best for a patient. When establishing prior authorization protocols, insurers selectively use clinical guidelines to determine a course of treatment, instead of their proper use as a starting point. But physicians know better: patients cannot be treated as a monolith, and final clinical decisions must always rest with providers and patients.”
Regardless of whether your practice decides to participate in this gold card program, ACG is committed to helping ease your administrative burdens.
We invite ACG members to take advantage of our prior authorization letter generator – now with an expanded library that includes five new IBD treatments:
- Adalimumab – Dose Escalation
- Combination Biologic Therapy
- Certolizumab Pegol – Dose Escalation
- Infliximab – Dose Escalation
- Ustekinumab (Stelara) – Dose Escalation
These treatments join more than a dozen other letters already in our library, including medications for Chronic Idiopathic Constipation, Hepatic Encephalopathy, IBS-C, and IBS-D.
Our tool makes it easier than ever to create custom letters. Simply select a treatment, add the relevant clinical findings specific to your patient, and hit ‘submit’! ACG does not store any patient information, and you can edit the letters after downloading.