Prior Authorization Gold Card Pilot case study
Value-Based Care Case Studies
Abstract
This case study explores a four-year pilot program between Asheville Neurology Specialists and a local South Carolina payer to streamline the prior authorization (PA) process for toxin injections used in treating migraines and headaches. The goal was to reduce administrative burdens, improve healthcare quality, and decrease costs. Asheville Neurology followed insurance policies and completed a Toxin Attestation Fax Form for efficient authorization. The pilot resulted in improved collaboration between the practice and payer, reduced administrative work, and better patient access to treatment. The pilot also highlighted the potential of Gold Card programs, which exempt providers with consistent approval rates from PAs, and are being adopted by other states and insurers.
Introduction
Prior authorization continues to be an area of burden for many practices and physicians. Asheville Neurology Specialists worked with a local payer to pilot and expedite the prior authorization (PA) process for toxin administration for migraine/headache patients. This case study examines a prior authorization Gold Card pilot program to reduce the prior authorization burden, and conducted over four years.
The AAN’s Care Delivery Subcommittee, under the guidance of the Medical Economics and Practice Committee, set out to better understand different care delivery models, their core functions and features, and the professional and personal advantages and disadvantages of such models compared to traditional fee-for-service care delivery and reimbursement. To better understand using a Gold Card program, the Care Delivery Subcommittee worked with Business Administrator member Carolyn M. Chamberlain, CMPE, CEO of Asheville Neurology Specialists, to provide insight into a Gold Card pilot with a local payer. Responses below represent the individual experiences of the contributors and are not the official opinion of the AAN or Asheville Neurology Specialists. Responses below represent the individual experiences of the contributors and are not the official opinion of the AAN.
Value proposition
Value proposition to the patient
- Improved patient outcomes and satisfaction
- Timely access to care
Value proposition to the provider
- Reduced administrative burden
- Increased communication and collaboration among team and payer
- Increased access to training and education
Value proposition to the health system
- Increased cost savings and resource efficiency
- Increased opportunity for improved outcomes and patient satisfaction
The care model
The pilot was conducted over four years between Asheville Neurology Specialists and a local South Carolina payer. The care model implemented through the pilot agreement between Asheville Neurology Specialists and payer focused on improving the prior authorization process for toxin injections used in migraine/headache treatment. The primary objectives were to streamline the approval process, reduce administrative costs, and improve health care quality. Key responsibilities for Asheville Neurology included following insurance’s medical policy, using toxin injections only when clinically appropriate, and completing the Toxin Attestation Fax Form to ensure accurate, efficient authorization requests.
When compared to the Gold Card program, the pilot focused on specific toxin injections and utilized a dedicated fax form, while the Gold Card program exempts providers with consistent approval rates from the prior authorization process for certain services. As of 2024, several states and United Healthcare are adopting Gold Card programs to further streamline authorization.
The pilot agreement was developed to improve the efficiency of the approval process for toxin injections used in the treatment of migraines. The overall aim was to enhance the quality of care and reduce administrative costs.
How it works
The pilot agreement between insurance and Asheville Neurology Specialists aimed to streamline the prior authorization process for toxin injections used in migraine treatment, improving efficiency and reducing administrative costs.
The local payer audited medical records to ensure compliance, conducting audits at intervals and reviewing patient records to confirm accuracy. The Toxin Attestation Fax Form played a vital role in ensuring adherence to medical policy, streamlining authorizations, and enabling audits. The Toxin Attestation Fax Form required information indicating the diagnosis code, CPT code used, and medication being administered using the appropriate J-code.
A major outcome of the pilot was the creation of a patient navigator role, improving access to toxin therapy. Ultimately, the process shifted from fax to an online portal for authorizations. However, challenges arose when the portal failed to function properly.
This model supported high-value care through improved outcomes, lower costs, and enhanced clinician and patient experiences. It also promoted health equity by improving access to care, ensuring timely treatment, and reducing administrative burdens for employees.
The provider experience
Asheville Neurology Specialists associated this pilot project with significant reduction in administrative burden, increased communication and collaboration among team and payer, and the creation of a patient navigator role, which improved patient access to care and supported the neurologists. The practice saw improved patient outcomes and satisfaction and an increase of timely access to appropriate care.