Austin, Texas — To streamline the medical preauthorization process for physicians, several states, including Texas, have introduced “gold card” laws aimed at exempting commonly approved procedures or prescriptions from repetitive checks. However, the anticipated simplification has not unfolded as expected, and the laws often fall short of their promise.
Under the 2021 Texas gold card law, a health insurer or health maintenance organization (HMO) is required to waive preauthorization if a provider has had a 90% or higher approval rate during a six-month evaluation. This exemption, designed to be automatic, should relieve some of the bureaucratic pressures faced by healthcare providers.
Despite the intent to ease processes, a mere 3% of Texas healthcare providers have benefited from the gold card exemption, as reported by a January 2023 survey from the Texas Department of Insurance. This figure is troublingly low, given the high expectations set by the law’s introduction.
The reality of achieving the necessary approval rate is complicated by the granular nature of Current Procedural Terminology (CPT) codes, according to Dr. Zeke Silva, a radiologist and chair of the Council on Legislation at the Texas Medical Association (TMA). For instance, different codes exist for slight variations in the same diagnostic test, complicating the accumulation of approvals needed to qualify for a gold card.
The challenges extend beyond coding issues. The lack of transparency from insurance companies about the criteria for awarding gold cards remains a significant barrier, as noted by Silva. Without insight into the decision-making process, providers cannot adapt to meet the unspecified standards impacting gold card distribution.
In response, the TMA is advocating for legislative changes, including the elimination of the five-case minimum and extending the validity of gold cards from six months to a year. Such amendments aim to further reduce the administrative workload on healthcare providers, enhancing focus on patient care over paperwork.
Moreover, nationwide, states such as Arkansas, Colorado, Louisiana, Montana, and West Virginia have also adopted similar legislation, each with varying degrees of success and specification. Colorado’s recent law, for instance, mandates a collaborative program to be devised by January 1, 2026, to alleviate authorization requirements effectively.
The evolution of gold card laws reflects an ongoing exploration for solutions that genuinely unburden medical professionals from administrative constraints while still ensuring patient care integrity. Emily Donaldson, a principal at the consulting firm Avalere in Washington, D.C., acknowledges the diverse approaches and outcomes observed across these states.
While initiatives like these are well-intentioned, the implementation and real-world effectiveness can vary significantly, suggesting a need for ongoing adjustments and learning from each state’s experiences.
As these laws continue to develop, there remains a cautious optimism that with informed refinement, the barriers currently preventing widespread adoption and effectiveness of gold card laws can be overcome, ultimately facilitating a more efficient healthcare system focused on patient outcomes rather than procedural approvals.
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