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Gold Star Program Reduces Prior-Auth Burdens

The Carlat Psychiatry Blog, Volume , Number ,
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Texas state legislators recently passed a bill that will greatly reduce the prior authorization workload. Will this open the door to the rest of the country?

A law recently went into effect in Texas that aims to ease the burden of medication authorization. In this article, I’ll show you how to make the most of this status to benefit both you and your patients.

Gold carding in the Lone Star state

In September 2021, Texas state legislators passed a bill that will greatly reduce the prior authorization workload. Known as the “Gold Star system,” it exempts physicians who have a 90% prior authorization approval rate over a six-month period on certain services from future prior authorizations on those services. Hopefully, this trend will spread to other states.

The new system is a response to the troubling growth of prior authorization requirements. While originally intended to apply to a small percentage of high-cost procedures, prior authorizations are now ubiquitous. While these authorizations take up a large portion of administrative time, the majority are eventually approved. Hence, there has been interest from patients, medical societies, and policy makers to reduce them.

To gain this Gold Star rating, all a physician needs to do is to show sustained (6 months in this case) approval of their prior authorizations with state regulated insurance companies. By proving that most of your authorization requests are approved, you can be exempted from future burdens. The new law does not require a perfect track record, but an approval rate of at least 90% is needed.

This reform falls in line with AMA principles that call for prior authorizations to identify “outlier” prescribing habits. It is also supported by some insurers, who have developed similar plans to reduce prior authorizations for physicians who follow evidence-based practices.

Next steps if prior authorization is denied

When prior authorizations are denied, the first thing to consider is whether the same or similar medication can be obtained through a low-cost pharmacy. Patients can often find affordable options for oft-denied medications like the modafinils and the z-hypnotics through GoodRx.com. Some pharmacies keep a list of low-cost generics, often around $4, although some of those programs charge an annual fee.

For brand-name medications, the manufacturer-supported patient assistance programs may provide free medications, but these programs are usually restricted to low-income and uninsured patients. Several clearinghouses help process applications to these programs (see the table below).

Pricing Resources
GoodRx.com Finds a nearby pharmacy with the lowest price for each drug.
Discounted pharmacies CostPlus, Health Warehouse, Blink, and Honey Bee provide discounted meds by mail for all patients. RxOutreach offers discounts for low-income patients.
Patient Assistance Clearinghouses These programs connect uninsured, low-income patients to medication assistance programs:

www.medicineassistancetool.org

www.needymeds.org

www.rxassist.org

Online prior authorizations

Online programs can streamline the prior authorization process. The most well-known is CoverMyMeds LLC. This free site connects providers with pharmacies and health insurance plans to streamline prior authorizations and improve efficiency.

CARLAT VERDICT

Sign up for the Gold Star if you live in Texas. If not, online programs can ease your prior-auth woes and low-cost pharmacies and patient assistance programs can help your patients fill meds that insurers deny.

For more on this topic and to earn CME credit, see the article, Prior Authorizations for Psychiatric Medications: A Primer for Frustrated Clinicians, featured in the April 2022 issue of TCPR.

-Tony Thrasher, DO. President, American Association for Emergency Psychiatry (AAEP). Medical Director of Crisis Services, Milwaukee County Behavioral Health, Milwaukee, WI. Clinical Associate Professor, Medical College of Wisconsin, Milwaukee, WI.

Dr. Thrasher has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

 


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