Unlocking Efficiency: How A Lab Gold Card Program Can Transform Prior Authorization

Prior authorization (PA) is exhausting. It is exhausting for providers to jump through the required documentation hoops. It is exhausting for patients who wait through appeals to determine if they are covered for the healthcare their providers say they need. And yes, it is exhausting even for the payers who insist PA is necessary to control costs and ensure healthcare dollars are spent wisely. In short, the healthcare supply chain is exhausted — and well-crafted gold card programs may be the solution.

State and federal governments are noticing the exhaustion and intervening. In January, the CMS finalized the Interoperability and Prior Authorization Rule, which requires plans participating in federal health insurance programs to accelerate and simplify their PA decisions. The rule, which takes effect in January 2026, sets new decision timeline requirements of 72 hours for expedited requests and seven calendar days for regular requests. CMS estimates this will cut prior PA approval times in half for some plans.

Another measure, the Improving Seniors' Timely Access to Care Act, requires plans participating in Medicare Advantage to report to CMS on their levels of PA use and establish an electronic PA system to accelerate decision-making.

States are also acting. In 2023, 30 states considered legislation to limit PA requirements. Recently, "gold carding" legislation, which grants exemptions to providers with a strong track record of previous approvals of requests, has become one of state policymakers' preferred approaches to minimizing prior authorization requirements.

Six states (Arkansas, Colorado, New Mexico, Texas, West Virginia, and Wyoming) have passed some form of gold carding program, while over a dozen more are considering it.

In response to this pressure and complaints from patients and providers, some plans voluntarily reduced their PA requirements. For example, LA Care Health Plan has removed 14,000 billing codes (24%) from its list of those requiring PA. Other insurers, including Blue Cross Blue Shield of Michigan and Cigna, have taken similar measures. Others, like UnitedHealth Group, are creating gold card programs for qualified providers.

Gold carding for labs

According to the American Clinical Laboratory Association, overly aggressive prior authorization practices harm patients and laboratories and negatively impact patient care. Waiting days for PA approval delays test results and could harm patients, while proceeding without approval risks difficulties with reimbursement.

Although most of the criticism and legislation of PA has centered on how it affects clinicians, medical labs are also impacted. Until recently, PA was generally not required for lab tests. However, that has changed since the rise of genetic and molecular testing. As more labs add sophisticated testing to their services, they will likely encounter preauthorization requirements.

According to the American Clinical Laboratory Association, overly aggressive prior authorization practices harm patients and laboratories and negatively impact patient care. Waiting days for PA approval delays test results and could harm patients, while proceeding without approval risks difficulties with reimbursement.

Gold card legislation focused solely on clinicians fails to ensure quality throughout the continuum of care. A physician might be exempted from PA, but more is needed to address the quality of the rendering lab they select. A gold card program that includes labs can help guarantee quality of care.

This solution works for both plans and labs. It eliminates PA for top-performing labs and eases plan workflows while controlling spending and preventing abuse. This lab gold card program utilizes a network of high-quality labs organized and run by a lab benefits manager (LBM). It is exclusively for genetic testing, the fastest growing and often most expensive testing segment.

Gold card labs benefit from reduced or otherwise minimized PA requirements, allowing them to work more efficiently and confidently so that they will be reimbursed according to their network agreements. They will also enjoy the prestige of belonging to the exclusive, high-quality network.

Here's how it works:

To earn gold card status with an LBM and health plans, labs would have to meet the following criteria:

• Submission of their lab-developed tests for an evaluation of their processes, quality, and expertise
• A threshold of PA requests for eligible procedures within the most recent ten months
• An approval rate of 90% or higher for eligible procedures within the past ten months and
• Willingness to provide supporting documentation for ongoing audits

The lab gold card audits would use the National Committee for Quality Assurance (NCQA) methodology to assess gold card labs and their procedures based on performance criteria and established baselines. The audit process would include:

• Monthly quality reporting and monitoring of all labs
• Quarterly audits performed of all gold card labs using NCQA methodology
• Additional special audits triggered by utilization variances; and
• Any gold card lab that fails an audit would be placed on a corrective action plan that includes a monthly audit for three consecutive months

Plans would benefit from joining with an LBM experienced in lab contracting and evaluating new tests. This would drive access to quality tests while simplifying the complexity and costs of genetic testing, ensuring patients get the right test for the right treatment at the right cost.

• Increased plan savings
• Simplified administration
• Improved patient and provider experience
• Reduced potential for waste

The PA process is changing to become faster, more accessible, and less expensive for all involved. Now, labs, patients, and plans can experience that new reality through an LBM-managed gold card network.

Alex Sommer is the vice president of state government affairs at Avalon Healthcare Solutions. Sarah Bretz is a senior product manager at Avalon Healthcare Solution and oversees genetic test management solutions.