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Prior authorization of medical, behavioral, dental, and/or waiver services is an important tool for ensuring that care provided to members is high quality, evidence-based, and cost-effective. However, providers and members alike have lamented that prior authorization can be overly complex and impede the timely delivery of services. The struggle for utilization review organizations is to balance accountability in the system with efficient processes that reduce provider burden.
In 2018, several groups, representing both providers and payers such as the American Hospital Association (AMA), America’s Health Insurance Plans (AHIP) and others, came together to establish a consensus statement on improving the prior authorization process.
One tenet of that consensus statement is employing the selective application of prior authorization based on a provider’s performance on specific quality measures, adherence to clinical guidelines, and evidence-based medicine. The goal of this special protocol, often referred to as “Gold Card” or “Gold Carding,” is to reward providers who consistently show that their standard of care is in line with evidence-based practices with the ability to bypass certain prior authorization requirements.
Since 2018, Gold Card programs have increased in prevalence, and both federal and state legislation has advanced to compel payers to create these opportunities for providers.
In 2022, AHIP conducted a survey of commercial plans regarding prior authorization, including Gold Card programs. The survey found that while use had increased and many believed that they had reduced administrative burden and improved provider satisfaction, there were some pointed barriers to their success. Such barriers include providers still submitting prior authorizations manually and programs being limited to clinical areas where there were clear and consistent clinical standards of care.
Telligen’s Holistic Blue-Ribbon Approach
Telligen’s proprietary Blue-Ribbon Program breaks from using specific code-based algorithms to incentivize providers, favoring a more holistic, trend-based approach. Our algorithms identify providers with a history of submitting complete and accurate requests for medically necessary services, limited need for additional information, and a track record of approval. Criteria for qualification can be customized to a client’s specifications while retaining the fundamentals of the program.
Providers who meet specified criteria receive auto-approval of program requests upon entering minimal demographic and service information into our proprietary Qualitrac system. Paired with provider education, to increase electronic submission, and a robust compliance auditing process on the back side, the Blue-Ribbon Program seeks to eliminate barriers that hinder the long-term success of other, more static programs.
As a value-add, Telligen’s Blue-Ribbon providers also can receive reporting that shows their algorithm-based outcomes to allow them to monitor their own performance.
Auditing/Compliance
With a Blue-Ribbon program, the key to accountability and continued value is quality monitoring. A random sample of prior authorization requests from each Blue-Ribbon provider is subjected to a quality review, to validate medical necessity, evidence-based practice and appropriate supporting documentation. Because only minimal information is collected before the service, if selected for review, clinical documentation is requested to validate the medical necessity of services. Any provider deemed out of compliance may lose their Blue-Ribbon status.
Wyoming Medicaid’s Blue-Ribbon Program
In partnership with Wyoming Medicaid, Telligen launched its Blue-Ribbon Program in late 2023. While a limited number of providers met the program’s initial rigorous standards, results were promising, and provider interest in qualifying for the program grew. As a result, additional providers were added to the initial cohort. Program education is available quarterly for providers.
To qualify for inclusion in the program, providers must submit a minimum number of reviews per quarter and have a Request for Information (RFI), Outcome Not Rendered (ONR), and Denial Rate below an identified threshold. A percentage of monthly reviews are audited to ensure program quality, and education is provided for any provider that does not meet those standards. After training, a provider that remains out of compliance is at risk of removal from the program.
Reducing Provider Burden without Losing Accountability
For utilization management organizations looking for a way to reward providers and reduce their administrative burden, Gold Card programs provide a pathway while preserving the accountability and integrity of the evidence-based criteria process. Telligen’s Blue-Ribbon program meets the intent of the 2018 consensus statement on improving the prior authorization process but takes it a step further, providing a fresh take with an algorithm that is simple to administer and utilizes a holistic approach to evaluating provider compliance.