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UnitedHealthcare’s Gold Card Program Streamlines Prior Authorization for Radiology, but Payment Challenges Remain
November 4, 2024On September 3, UnitedHealthcare (UHC) unveiled additional details about its new “gold card” program, which aims to simplify prior authorization (PA) processes for certain healthcare services. Radiology practices are poised to benefit from this initiative, with more than one hundred radiology-related CPT®1 codes now covered under the gold card program.
The gold card program was first introduced in early August 2024. It makes provider groups that consistently adhere to medical policies and evidence-based care guidelines eligible to eliminate prior authorization requirements for applicable procedure codes. As a result of the program’s expansion, radiology practices can expect a reduction in their prior authorization (PA) requests. They can transition to a “simple notification process” for approved CPT codes instead of the standard PA process. Among the codes included are imaging procedures such as computed tomography (CT) scan of the abdomen without contrast, breast magnetic resonance imaging (MRI), and whole-body positron emission tomography (PET) imaging.
According to UHC’s announcement, this effort is part of a broader initiative to modernize and streamline the PA process, often cited as a barrier to timely care. “Prior authorization serves as an important checkpoint to help ensure a service or prescription is a clinically appropriate option. But UnitedHealthcare is taking steps to modernize and streamline the process,” the company stated in its release.
The gold card status will apply to UHC’s commercial, individual exchange, Medicare Advantage, and Medicaid plans. To qualify, provider groups must meet three criteria over the past two years:
- Being in-network for at least one line of business
- Processing at least ten eligible prior authorizations per year and
- Maintaining a 92% approval rate on these requests.
Despite this initiative, healthcare stakeholders voiced mixed reactions on social media. Tyler Scheid, JD, of the American Medical Association, questioned the program’s comprehensiveness in a post on X (formerly Twitter). He raised concerns about the program’s stringent 92% approval rate requirement, which applies to all eligible codes rather than individual procedures.
UHC is one of several payors attempting to address the challenges of prior authorization. Earlier this year, LA Care Health Plan and Cigna announced significant reductions in their PA requirements, though the scope of these changes varied across specialties. According to the 2023 American Medical Association’s (AMA) prior authorization survey, 93% of the 1,000 physician respondents reported adverse effects on clinical outcomes, and nearly one-quarter cited severe adverse events because of PA-related delays.
Removing PA Requirements Does Not Guarantee Payment
While gold card programs are a key step toward alleviating the administrative burden on healthcare providers and improving access to care, they do not guarantee payment for services. This is a critical distinction that radiology practices and other healthcare providers must be aware of as they navigate this new process. Practices must remain vigilant for potential denials related to services deemed medically unnecessary or investigational, which can still occur even with gold card status.
Gold card program requirements vary across payors. There is also a federal Medicare Advantage gold card program, and some states, including Texas and West Virginia, have implemented gold card programs. The variability in requirements and covered procedures can complicate the process for healthcare providers.
Radiology groups must closely track which gold card programs apply to their services and monitor any denials, even for procedures covered by these programs. XiFin recommends tracking payment trends, monitoring reimbursement timeliness, and measuring appeal success rates, as these metrics are crucial for understanding the net benefit of gold card initiatives. Moreover, even when prior authorization is granted and the appropriate code is submitted, payors may still deny claims, further complicating revenue cycle management for radiology providers.
While gold card programs, like UHC’s, move in the right direction, radiology practices must remain proactive in monitoring their claims and denials to ensure that these efforts to streamline PA genuinely lead to better outcomes for patients and providers. As more payors adopt similar programs, consistency and data transparency will be essential to their success.
Data transparency is also crucial to understanding how payors are reimbursing your practice relative to others. XiFin’s Payor Rate Transparency Monitor allows you to see in-network rates for three large national payors. Benchmark your contracted rates for five radiology codes.