Gold carding: what it exempts and what it does not

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Gold carding exempts a provider from prior authorization for specified services, on the basis that their historical requests were approved at a high enough rate that reviewing them adds nothing. Several states have legislated it and a number of plans run voluntary programmes. It is genuinely valuable and it is consistently oversold.

#How it works

1. A look-back period
   The plan examines your requests for a defined service over a defined window, commonly a year.
2. An approval threshold
   If your approval rate exceeds a threshold, frequently in the range of ninety per cent or higher, you qualify.
3. A minimum volume
   There is usually a floor on the number of requests, because a perfect rate on four requests proves nothing.
4. An exemption period
   The exemption runs for a defined term and is re-evaluated. It can be revoked.

#What it does not do

• It is per service, not blanket. An exemption for one procedure says nothing about the next.
• It is per payer, and usually per plan within that payer. It does not travel.
• It does not remove the need to verify eligibility, which remains just as necessary.
• It does not remove medical necessity as a standard. It removes the prospective review; retrospective review generally survives.
• It can be revoked if your pattern changes, which means the documentation discipline that earned it still has to hold.

#Earning it deliberately

Approval rate is the qualifying metric, which means the behaviours that raise approval rate are the ones that earn exemption. Reading the payer's policy for your common procedures, capturing the criteria elements as a matter of routine, and not submitting requests you know are short all move the same number.

There is a converse worth stating: submitting weak requests speculatively depresses the rate that determines eligibility. A practice that submits everything and appeals what sticks is, among other things, disqualifying itself.