Bill Would Exempt Prior Authorization for Physicians with Good Records

The Academy has endorsed a new prior authorization reform bill that would give certain Medicare Advantage providers an exemption from some prior authorization requirements.

The exemption would apply to specific items, services or groups of similar services on which a provider has an approval rate of 90% or better during the preceding plan year.

The Texas members of the House — Reps. Michael C. Burgess, MD, R-Texas; Vicente Gonzalez, D-Texas; and Ronny Jackson, MD, R-Texas — introduced HR 7995, the Gold Card Act. They modeled the federal bill on Texas’ HB 3459, which ophthalmologist Dawn Buckingham, MD, co-introduced and helped shepherd into state law. Dr. Buckingham is a member of the Texas State Senate.

The new bipartisan U.S. House bill complements the Improving Seniors’ Timely Access to Care Act, which now has more than more than 330 co-sponsors in the House and Senate. 

In addition to giving the exemptions, HR 7995, if enacted, would: 

• Require Medicare Advantage plans to notify each provider who qualifies no later than 30 days before the first day of each plan year.
• Limit reviews for gold card status to no more than once every 12 months.
• Allow physicians to appeal gold card revocations they believe were wrongly decided.
• Require the secretary of the U.S. Department of Health and Human Services to issue a rule on the use of prior authorization by Medicare Advantage plans. The rule would ensure continuity of care for individuals transitioning to, or between, coverage to minimize disruption of ongoing treatments covered by previous plans.

Use the Academy’s online advocacy tool to urge your representative to support the Gold Card Act.