Priority Health, Altruista build electronic improvement for healthcare preauthorization

GRAND RAPIDS—Priority Health, the second largest health insurer in Michigan, has gone live with the GuidingCare Authorization Portal from Reston, Va.-based Altruista Health. The aim is to save Michigan healthcare providers time in seeking preauthorization on behalf of Priority Health members.

Providers can now stop faxing and phoning in requests and get nearly immediate responses through this new electronic portal, developed in a unique collaboration between Altruista, Priority Health and its parent organization, Spectrum Health System.

Preauthorizations for treatment support value-based care by aligning care with the latest clinical guidelines. But industry research shows that most providers turn first to the fax machine, phone or U.S. mail to obtain preauthorization. These manual processes slow the care process and create friction between health plans and providers, with the potential to create member uncertainty and anxiety. Some 80 percent of requests eventually are met with approval, so finding a way to streamline turnaround times can make a significant positive impact to resources.

Priority Health and Spectrum Health are an integrated health system serving nearly 1 million health plan members and representing 97 percent of Michigan’s primary care practices and 96 percent of the state’s hospitals. This collaborative three-way project emerged during the implementation of Altruista’s GuidingCare care management technology platform at Priority Health last year. GuidingCare is Altruista’s technology platform for care management that connects stakeholders for a 360-degree view of the member. Seeing the success of the care management platform, Priority Health and Altruista set out to design an ideal preauthorization tool.

“We spoke with a group of providers to hear their preferences and needs when it comes to going through the preauthorization process,” said Ann Donnelly, vice president of care and utilization management at Priority Health. “Our providers are on the frontlines of delivering high-quality care to their patients and our members, so implementing the Portal is going to help solve some of the preauthorization issues and delays when it comes to them receiving that care.”

Through the portal, Priority Health and Spectrum Health providers receive authorizations in a matter of moments, allowing more complex requests to be quickly routed for review of medical necessity. All of this is completed within the portal through one-click messaging that offers document and image upload on both ends. Another efficiency of the Portal is the virtual elimination of concurrent reviews for inpatient stays. These previously required daily phone calls between the hospital physicians and health plans during inpatient stays. Now dates or units of care can be extended right in the portal.

Altruista saw an opportunity to custom-build a portal that would serve Priority Health and Spectrum Health’s needs, but also one it could replicate for other customers. The process was complex since it involved building a new tool in the midst of implementation of its care management platform. Altruista’s product, engineering and implementation teams worked in tandem, as well as coordinating with Priority Health’s teams.

“The value-add for the system is that Authorization Portal integrates with the world’s leading clinical guidelines to assure an optimal treatment path is being provided,” said Mike McKitterick, executive vice president of clinical services at Altruista. “Preauthorization requests are instantly bounced off the latest clinical guidance to validate appropriateness.”

GuidingCare integrates and is certified with the world’s most comprehensive and respected clinical guidelines, MCG Cite AutoAuth and InterQual Connect. The portal went live last fall, and more information can be found on Altruista’s website.

More about Priority Health at www.priorityhealth.com.

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