On Oct. 1, UnitedHealthcare's national prior authorization gold-card program went into effect. The payer first announced the program in August, and debuted its list of eligible procedures on Sept. 1, which included several orthopedic and spine-related codes.
Here are seven things for orthopedic and spine specialists to 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 spine procedures eligible for the program.
6. Here is a list of orthopedic procedures eligible for the program.
7. While surgeons are split on the benefits of a potential gold-card program, many are cautiously optimistic about its benefits.
"The UCH gold-card program, if executed fairly, has the potential to be beneficial for both patients and providers," Nolan Wessell, MD, an orthopedic surgeon and assistant professor in the department of orthopedic surgery at the University of Colorado School of Medicine in Aurora, told Becker's.
However, as a veteran of prior authorization projects within his own institution and at the state level as a board member of the Colorado Orthopedic Society, Dr. Wessell offered a note of caution. "Currently, delays in prior authorization lead to significant delays for patients as they await surgery, which leads to potential clinical harm, dissatisfied patients and inefficient use of surgeon's time, adding to costs within the healthcare system as a whole," he said.
Read more about the program here.