On Oct. 1, UnitedHealthcare's national prior authorization gold-card program went into effect. The payer announced the program in August and rolled out its list of eligible procedures on Sept. 1, which included several ASC-related codes.
Here are seven things ASC leaders should know about the program:
1. Providers will not need to apply for the gold-card program, but they will have to meet certain eligibility requirements, including being in network for at least one UnitedHealthcare commercial, individual exchange, Medicare Advantage or community (Medicaid) plan; meeting a minimum annual volume of at least 10 prior authorizations each year for two consecutive years across gold-card-eligible codes; and having a prior authorization approval rate of 92% or more across all gold card-eligible codes for each of the review years.
2. Providers that earn gold-card status are required to complete advance notification for services, but no clinical information will be requested.
3. UnitedHealthcare will conduct annual evaluations for gold-card qualification. Gold-card status determinations will be effective Oct. 1 every year.
4. Providers may lose gold-card status because of patient safety issues, failure to cooperate with quality and patient safety activities, failure to make timely responses to requests for information, or no longer meeting program requirements.
5. Here is a list of GI procedures eligible for the program.
6. The American Gastroenterological Association and the American College of Gastroenterology issued statements criticizing the program.
7. While several industry groups have criticized the program, some physicians are cautiously optimistic it will have benefits for patients and providers.
"The proposal behind the gold-card program from UHC is one that will work to help alleviate pre-certification requirements if the program works as designed. The qualifying criteria for provider enrollment is something that will help raise the standards of care for all patients receiving treatment," Zeeshan Tayeb, MD, owner and medical director of Pain Specialists of Cincinnati, told Becker's. "It would be an additional incentive if providers qualifying for the UHC gold card enrollment were provided an elevated fee schedule for services."
Read more about the program here.