As a family physician, I have experienced first-hand how burdensome the prior authorization process is for patients and physicians. Prior authorization poses other challenges, including health insurance benefits and eligibility gaps, which are tied to evolving coverage rules. That is why several states, like Texas and West Virginia, and 58% of health plans adopted "gold carding," a method of waiving or reducing prior authorization requirements for physicians with proven records of delivering high-quality health care. For example, BCBS Michigan recently announced the expansion of its gold carding program, relaxing requirements for physicians with a low prior authorization denial rate, minimal prior authorization requests, and risk-based contract participation.
The reaction to gold carding has been mixed, with concerns about increased paperwork and potential quality and cost implications. A recent AHIP survey found that one-fifth of responding health plans said gold carding led to reduced quality and increased spending without substantial benefits. Additionally, gold carding programs can be difficult to implement; this was the top reason cited for discontinuing them, accounting for 75% of the responses. Another concern mentioned in the study was gold carding programs' inability to offer alternative treatment recommendations that could help avoid lower-quality or unsafe care.
Amid this uncertainty, a data-driven alternative called "green lighting" has emerged as a more efficient and flexible approach to prior authorization. Green lighting helps make the prior authorization experience more personalized for physicians and automated while maintaining quality and cost control. This is because it automates authorization processes using real-time, data-driven, physician-specific insights.
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Green lighting: A data-informed alternative
Green lighting offers a more precise, efficient approach to reducing the burden of prior authorization by leveraging real-time, physician-specific, and code-specific data. Green lighting uses real-time data to automatically place physicians on (or off) specific authorization workflows without waiting months for retrospective data to analyze their performance. For physicians with high rates of prior authorization approvals, the process involves a notification path for those services rather than requiring approval. Moreover, green lighting is extremely adaptable; it can change rapidly in response to changes in physician service requests. In contrast, gold carding relies on months of retrospective data, which must be analyzed manually. Gold carding manually assigns physicians to broad authorization programs that often rely on data from six or more months ago. Most notably, prior authorization loses its watchdog or sentinel effect with gold carding: with no one "watching," unnecessary or unsafe services may be missed.
Additionally, green lighting enables compliance with various government-driven gold carding mandates. Green lighting can be segmented at the practice or physician level to enable the necessary combination of services, approving an entire group of physicians, particularly if they bear risk. This is of utmost importance because the eligibility for and extent of gold carding programs can differ significantly. For instance, some state gold carding laws do not impact all health plans or lines of business, requiring plans to manually segregate figures according to their member populations, physicians, and service categories. Because legacy prior authorization systems need more technological infrastructure to gather such data, health plans will encounter substantial costs and complexities during implementation. On the other hand, green lighting, driven by innovative, AI-supported technology, addresses these variances without the need to reconfigure systems or perform the work manually.
Here's a deeper dive into the key advantages of green lighting and why it's considered an essential shift in the health care benefits industry:
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Reduced paperwork
Green lighting offers a major advantage over gold carding by significantly reducing paperwork and expediting the prior authorization process. By relying on automated data and analytics, green lighting not only minimizes administrative burdens for physicians and health plans, but also reduces the likelihood of errors, resulting in more accurate determinations and faster access to care for patients.
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Better patient results
Green lighting prioritizes the use of real-time data to make informed decisions, unlike gold carding, which acts retrospectively and can take up to six months to evaluate and approve physicians. This ensures that high-quality care remains at the forefront of the prior authorization process. By continually monitoring and analyzing service requests, health care organizations can identify the most efficient physicians, ultimately leading to an improved process that results in better patient outcomes.
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Evaluation of physicians
One concern with gold carding is the potential to game the system. Physicians might aim to meet specific metrics to secure exemptions, potentially leading to data manipulation or overlooking critical aspects of care. Green lighting takes a more comprehensive approach by continuously monitoring service requests based on real-time analytics. This approach provides a more accurate, holistic assessment of the quality of care delivered, reducing the chance of manipulating the system.
The role of benefits consultants
Benefits consultants are integral to the success of green lighting, acting as facilitators and utilizing their expertise to guide employers as they navigate the complexities of health insurance, specifically the prior authorization process. What sets green lighting apart is its ability to help employers reduce physician friction without compromising on quality and cost control, which is often a challenge with the generalized approach of gold carding. With their knowledge of data analysis, compliance, and the latest industry trends, benefits consultants can help employers implement the new approach effectively. Green lighting's personalized analytics also allow benefits consultants to create customized benefits packages that meet their clients' unique needs.
A data-driven future
The adoption of data-driven techniques like green lighting is crucial to ensure that the industry keeps pace with advances in technology and patients' expectations. Green lighting's real-time, automated approach provides precise control without the delays or manual work associated with traditional gold carding. Importantly, it also maintains compliance with state-level and other gold carding mandates. Gold carding, while data-driven, faces challenges related to timing, manual vs. automated analysis, and program activation.
As more health care organizations recognize the advantages of green lighting, the focus will continue to shift toward data and analytics as essential tools for enhancing the quality, accessibility, and cost-effectiveness of care. This shift will help shape the future of health care and, ultimately, improve patient care.
Dr. Mary Krebs serves as Medical Director at Cohere Health. In addition, she teaches residents and medical students at a family medicine residency program in Dayton, Ohio.
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