Exempt oncologists who follow the pathway from prior authorisation
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.
Overview
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.
- Fragmented care and guideline gaps · Patients fall between specialists, wait for referrals and often do not get the treatment guidelines say they should.
- Incentives reward me-too drugs and marginal gains · The system pays the same for a drug that adds two months as for a cure, so companies race to copy rather than to cure.
- Not enough oncologists, nurses, pathologists, physicists · The number of people with cancer is rising faster than the workforce trained to treat them.
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