HIMSSCast: Direct contracting streamlines prior authorization
First Choice works with providers that are interested in working directly with employers.
Photo: Tetra/Getty Images
Jaja Okigwe is CEO of First Choice Health, headquartered in Seattle. The company is a benefits administration business that has one of the largest direct-contracted networks in the Upper West with nearly one million members in its network.
It's a provider-owned venture, created by hospitals and physician groups as an alternative to traditional health insurance, Okigwe said.
There are challenges in the size of an area. The middle of the country is a growing market right now, but First Choice has yet been able to make work areas that are too rural with small populations and not a lot of local employers. There are ongoing discussions with rural hospital associations.
Also, since the pandemic, employees have become far flung, working in different states.
"We're starting to create relationships across markets," Okigwe said.
For more on direct contracting and how it works to make health benefits more of a collaborative venture, listen to Okigwe's conversation with Susan Morse, executive editor of Healthcare Finance News.
Talking points:
- Direct contracting offers streamlined service and customized programs.
- First Choice Health has a limited network, the same as any other health plan.
- The prior authorization process is smoother. When they get a request, often First Choice calls up the provider to see what they want approved. "Just because you forgot to send us something doesn't mean we should delay surgery," Okigwe said.
- More set up is needed for direct contracting as these programs are more strategic, Okigwe said. During COVID-19, this was on the back burner but it's back on the agenda for 2024.
- Value-based care contracts are similar to Medicare Advantage but with pay at the commercial rate.
- One relationship has both upside and downside risk. Most are between that and fee-for-service.
More about this episode:
Three quarters of ACOs in direct contracting model earned savings
10 leading health systems join Transcarent's direct contracting ecosystem
CMS releases Interoperability and Prior Authorization Final Rule
AHA, others push CMS to revise prior authorization reform requirements
Current prior authorization practices are adding to burnout, surgeon general says
Email the writer: SMorse@himss.org
