# Exempt oncologists who follow the pathway from prior authorisation

Source: https://onco.cc/ideas/idea-cost-gold-card-oncology/  
OnCo record `idea-cost-gold-card-oncology` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

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.

## Fields

- Kind: Idea
- Last checked: 2026-09-10
- 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.
- Proposed 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

## Sources

- KFF: Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024: https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/

## Connected records

- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [National Comprehensive Cancer Network (NCCN)](https://onco.cc/institutions/nccn-org/)
- terms: [NCCN Compendium and drug compendia](https://onco.cc/terms/nccn-compendium/)
- bottlenecks: [Fragmented care and guideline gaps](https://onco.cc/bottlenecks/b-care-fragmentation/), [Incentives reward me-too drugs and marginal gains](https://onco.cc/bottlenecks/b-incentive-misalignment/), [Not enough oncologists, nurses, pathologists, physicists](https://onco.cc/bottlenecks/b-workforce/)

---
JSON: https://onco.cc/api/v1/entities/idea-cost-gold-card-oncology.json