As state lawmakers consider more controls over prior authorizations that health insurers require before covering certain medical care, Priority Health has launched a new system designed to make the process easier for physicians.
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The electronic portal that Reston, Va.-based Altruista Health Inc. designed for Priority Health automates the prior authorization process, providing physicians a quicker response on whether a patient’s procedure, diagnostic test, hospital admission or medical equipment is covered.
A physician’s request is automatically approved if it aligns with a health plan’s criteria for medical necessity.
The portal can also request further information from a physician electronically, eliminating the need for calls or faxes between offices. The portal may direct that added data to the insurer’s staff for review. Doctors can also check the status of a prior authorization request.
Altruista’s GuidingCare Authorization Portal — designed with Priority Health and its parent corporation, Spectrum Health — also features a care management component that gathers real-time data that track decisions and identify trends. That gives Priority Health added ability to review and decide whether to discontinue prior authorization for specific tests, procedures or hospital admissions.
The Grand Rapids-based Priority Health implemented GuidingCare’s health care management system in October 2019 and the utilization management program last September. Based on early data, Priority Health in May removed about 20 items from its prior authorization list, said Ann Donnelly, Priority Health’s vice president of care and utilization management.
“Now we have data that’s going to say, ‘If we’re going to turn something on for prior authorization, what value is that bringing to us? Is it worth the administrative cost for all of the stakeholders to go through that process, or should we turn it off?’” Donnelly said.
“We have information so we can adjust,” Donnelly added. “We now have the data that shows us by service how many prior authorizations are coming in, how many are we approving, how many are we denying, and what’s their cost. We can make educated decisions on the value of asking for that prior authorization, and if there’s no value in it, then why are we asking physicians to jump through them?”
Priority Health processes roughly 3,500 prior authorization requests a week, and 80 percent are approved.
Efficiency, checks and balances
Altruista worked directly with Priority Health and Spectrum Health to customize the prior authorization portal. The company works with more than 50 national and regional clients across the U.S.
By automating the workflow, the portal can create efficiency, reduce the administrative burden for doctors and health plans, and improve response times, said Mike McKitterick, executive vice president of clinical services at Altruista Health.
“It’s really helping to standardize those processes and create some efficiencies so that the transactions that come out of the approvals and denials are more predictable so providers very quickly pick up on what the standard of care is and what’s likely to be approved or what’s not likely to be approved,” McKitterick said. “Over time that helps the evidence-based care that the criteria is built on.”
Health insurers routinely use prior authorization as a check against high costs and to ensure physicians use care practices that are supported by evidence and are not ordering what they consider medically unnecessary. The process can often frustrate physicians who view it as intrusive and causing delays in needed patient care, adding to the tension that can occur between providers and insurers.
In partnering with Altruista Health, Priority Health looks to maintain the checks and balances of prior authorization with an automated process for physicians to use when seeking coverage approvals for their patients.
“We’re trying to walk that fine line,” Donnelly said. “We recognize the providers are on the front lines of delivering high quality care to our members, and we value that partnership with our providers. We wanted to help solve that problem, reduce that burden and make their lives better. I know they don’t like having to ask.”
Priority Health’s turnaround time on prior authorization requests after automating the process is now less than three days. Turnaround times previously varied based on the type of request.
“And as we continue to look at our data and identify what we might be able to turn off or move to auto approvals, those times are going to come down and come down,” Donnelly said.
Physicians push reforms
Priority Health’s adoption of the Altruista platform came as physician organizations have pushed to rein in prior authorization requirements that they say have gone too far and in some instances delay needed care or threaten patient safety. Frustrations with prior authorization requirements have even been cited as a contributing factor to physician burnout.
The Michigan State Medical Society has pushed for legislation in Lansing that would create new rules for prior authorization practices in the state.
A bill that unanimously passed the state Senate in April includes language requiring health insurers to make a standardized electronic request process available by Jan. 1, 2023. Senate Bill 247, sponsored by Sen. Curtis VanderWall, R-Ludington, is awaiting action in a House committee.
Michigan State Medical Society Chief Operating Officer Kevin McFatridge said the organization is still awaiting feedback on Priority Health’s portal, but that “electronic prior authorization process is where things are headed.”
“If the system is user-friendly, based on current evidence-based protocols, and more timely in issuing a decision, conceptually it is a good thing. It still does not address the number of required prior authorizations and whether those that are approved almost all of the time truly provide a value or cost savings to care delivery,” McFatridge wrote in an email to MiBiz. “It bears repeating: These requirements can create hassles for patients and add to physicians’ burden. Prior authorization rules vary by different payers, which require inconsistent workflow processes and submission of additional information through a manual process.”