Centene joins insurers waiving prior authorizations for top providers

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Dive Brief:

• Centene announced on Tuesday that it will launch a gold card program next month as the healthcare industry works to reform the prior authorization process.
• The program exempts high-performing providers from routine prior authorization requirements for specific medical services, procedures or prescriptions.
• More than 160,000 providers nationwide will immediately have access to the program based on their approval history with the insurer, documentation quality and compliance with plans' medical policies and regulatory requirements, the insurer said.

Dive Insight:

The program, called the National Performance-Based Gold Card Program, will only apply to certain outpatient services first, with Centene expecting to expand the scope of services and number of eligible providers over time.

Qualifying providers must submit a pre-notification before rendering services, but they’ll be able to give care without waiting for the insurer's approval, according to the announcement.

Healthcare providers have lauded gold card programs because they remove significant administrative barriers to completing prior authorizations. The programs also enable faster patient care, bypassing lengthy wait times for insurance approval.

Historically, insurers haven't been eager to adopt gold card programs voluntarily, fearing they will lead to over-utilization of expensive, unnecessary care.

However, nearly a dozen states have passed legislation mandating that insurers implement similar programs to mitigate delays in patient care and address physician burnout. More states, including New York, are also considering similar legislation.

Scrutiny on prior authorization has also come from the federal level, with the Trump administration securing voluntary pledges from major insurers last year to cut down on the processes. In April, insurers said they had cut 11% of prior authorizations so far.

Some health insurers are reading the writing on the wall and standing up their own gold card programs. Humana launched a program this year that waives prior authorization requirements for certain items and services for eligible providers.

UnitedHealthcare also expanded its program earlier this month, allowing more provider groups to qualify for so-called prior authorization fast passes. The company said the number of provider groups eligible for the well-liked program has increased by 80% since its start two years ago.

Still, provider groups and patients continue to decry prior authorizations. Providers say reforms have yet to meaningfully affect their prior authorization workloads, while patients continue to wait on approvals before getting the care they need.

Provider groups continue to push insurers to implement gold card programs, which were not explicitly part of the pledge's commitments to simplify prior authorizations.