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What the Heck is a Gold Card and Why is it the Future of Utilization Management?

Posted by Justin Adams on Dec 19, 2018 1:54:00 PM

When you hear the word “Gold Card” the typical person may immediately think about an American Express credit card—a baseline transaction tool that is also a gateway to perks and discounts that are designed to reward reliable buying patterns and top-tier credit (and to incentive continued behavior).

But the idea of a “gold card” isn’t restricted to just the consumer credit market—it has taken hold in a unique way in the healthcare industry, particularly affecting how healthcare providers submit “prior authorizations” and, correspondingly, how health insurance plans conduct “utilization management.” While arguably not as exciting as getting free airline and hotel points, our type of gold carding is infinitely more valuable to society and in bringing down the administrative costs of healthcare while increasing quality.

 

 

“Gold Carding”

“Gold carding” is the process by which a health plan can automate prior authorization reviews based on the past performance of a healthcare provider.

 
Gold Carding for Better Utilization Management

If a provider has a proven history of aligning with the plan’s rules of medical appropriateness, and if the provider consistently submits prior authorizations completely and accurately, a health plan can offer that provider a “gold card” to accelerate and streamline the review process.

Why Does Prior Authorization Need Acceleration and Streamlining?

In theory, prior authorizations should simplify the delivery of care to patients and help control costs. The process is straightforward: (1) a doctor orders a certain treatment or a prescription for a patient (2) the doctor’s back office revenue cycle team will then submit that treatment recommendation to the health plan with the goal of confirming that the health plan reimburse accordingly (3) the health plan reviews the submission and either authorizes or denies the treatment.

In practice, however, prior authorizations represent one of the most cumbersome, manual, and costly back office processes in the healthcare industry today. With administration alone costing the equivalent of $83,000/doctor/year, prior authorizations rely on human heroics by provider and payer teams as they bounce information back-and-forth (often via phone and fax) on hundreds of thousands of patient cases only to satisfy administrative box-checking. What results is a great deal of finger-pointing, perceived “gamesmanship,” and cycles of re-negotiating the same issues over and over again.

“Gold carding” is game-changer for providers and payers because it removes the overwhelming need to arbitrate each individual patient case, and instead employs data, rules, and tech-enabled workflows to resolve most cases.

Gold Carding Challenges

But gold carding is not without its challenges. In the past, due to the constraints of traditional software and workflow tools, “gold carding” has been a binary and static concept—health plans have had to decide between (1) using a static rule set for gold carding only the providers that most closely aligned to plan mandates or (2) treating all providers equally (i.e. not gold carding at all).

But now, thanks to A.I. and machine learning models that Digitize.AI has created, health plans have a new option for “Smart Gold Carding” that allows health plans to employ dynamic rules sets and predictive logic to measurably and systematically employ gold carding across provider institutions.

Where A.I., and Mia™, Fit In

Mia™, our System of Intelligence for Smarter and Faster Utilization Management, is the first of its kind smart gold card for health plans.

Meet Mia for Health plans

Mia™ employs machine learning with a cognitive feedback loop to guarantee that the right care by the right provider is delivered at the right time—and in accordance with the nuances of each health plan. Mia™ determines down to the physician level what historical patterns of quality care exist, and is smart enough to auto-approve the cases the health plan wants approved and triage the cases where they may need to be manual intervention or review.

And because Mia™ integrates directly with key systems (EHR, UM, etc), the system always has access to the data that are needed to make these decisions and continually learn as treatment trends evolve and plan rules change.

Click here to learn more about Mia

Lower Costs, Higher Net Promoter Scores, Better Utilization Management 

While the painful prior authorization process for providers receives a lot of the attention, studies consistently show that the cost to health plans for authorizations are at least twice as much as providers. Clearly the system is broken. The traditional salve of adding more bodies or outsourcing is no longer sustainable. Fortunately, through Mia’s smart workflows and machine learning there is a better way to reduce costs and turnaround time, and increase membership and care.

Health plans that have traditionally outsourced utilization management due to the manual nature can now bring it back in house and seamlessly integrate it with their current systems using our artificial intelligence technology. This can help health plans increase their net promoter scores by delivering authorization responses faster for a member.

Why We Care About This

I wrote a blog in late summer detailing my own experience with prior authorization for a knee MRI I had and discussed in details how broken the system was. I was so fired up then I ended post with #PriorAuthsSuck. To say that I would give my health plan a low net promoter score at the time is an understatement. All that frustration for a procedure I eventually received was just a lot more time and costs for the provider and the the plan. This was a concrete example of how Mia™ would have helped my health plan avoid that situation.

Read more here.

Getting Pragmatic

Let me be clear—A.I. won’t solve all of your prior authorization and utilization management challenges. If I told you that it would, you wouldn’t believe me anyway. These processes are necessary and valuable to the administration of cost-effective care, but they’ve become a quagmire of processes and rules that no silver bullet can untangle. But as we’ve proven with Mia™, A.I. does help address a crucial majority of issues within the current process. If you want to see Mia™ in action and learn how we can help your health plan, contact us at team@digitize.ai.

Justin Adams

Written by Justin Adams

Topics: AI, Prior authorization, Artificial intelligence, Pre-certification, Revenue cycle, "AI for Health Plans", System of intelligence, Gold carding, Utilization management