{"entity":{"id":"idea-cost-gold-card-oncology","kind":"idea","name":"Exempt oncologists who follow the pathway from prior authorisation","aka":[],"tldr":"If a practice's requests are approved almost every time, asking again wastes everyone's money; gold-card rules give such practices automatic approval and audit them instead.","summary":"Medicare Advantage insurers made nearly 53 million prior authorisation determinations in 2024 and overturned 80.7% of the denials that were appealed (KFF). Texas passed the first gold-card law in 2021: clinicians with approval rates above 90% are exempt from prior authorisation for those services. Oncology is well suited because on-pathway prescribing (NCCN categories 1 and 2A) is easy to audit retrospectively. Several insurers have announced gold-card programmes; making the rule statutory and pathway-based would extend it.","asOf":"2026-09-10","links":[{"label":"KFF: Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024","url":"https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/"}],"tags":[],"related":[],"cancers":[],"sections":[],"technologies":[],"targets":[],"drugs":[],"companies":[],"institutions":["nccn-org","asco"],"pathways":[],"terms":["nccn-compendium"],"trials":[],"people":[],"bottlenecks":["b-care-fragmentation","b-incentive-misalignment","b-workforce"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Gold-carding oncology practices with over 90% approval rates will cut prior authorisation volume by more than half with no increase in off-pathway prescribing on audit.","rationale":"Overturn rates above 80% mean most denials are wrong; the review adds delay and cost without changing the treatment.","test":"Compare gold-carded and non-gold-carded practices on time to treatment start, administrative hours, drug spend and pathway concordance.","maturity":"being-tested-at-scale","actor":"payer","cost":"small","horizonYears":1},"route":"/ideas/idea-cost-gold-card-oncology/","neighbours":{"institution":[{"id":"asco","kind":"institution","name":"American Society of Clinical Oncology (ASCO)","route":"/institutions/asco/"},{"id":"nccn-org","kind":"institution","name":"National Comprehensive Cancer Network (NCCN)","route":"/institutions/nccn-org/"}],"term":[{"id":"nccn-compendium","kind":"term","name":"NCCN Compendium and drug compendia","route":"/terms/nccn-compendium/"}],"bottleneck":[{"id":"b-care-fragmentation","kind":"bottleneck","name":"Fragmented care and guideline gaps","route":"/bottlenecks/b-care-fragmentation/"},{"id":"b-incentive-misalignment","kind":"bottleneck","name":"Incentives reward me-too drugs and marginal gains","route":"/bottlenecks/b-incentive-misalignment/"},{"id":"b-workforce","kind":"bottleneck","name":"Not enough oncologists, nurses, pathologists, physicists","route":"/bottlenecks/b-workforce/"}]}}