Guidewell is a not-for-profit mutual insurance holding company with over 18,000 employees that operates across the U.S. to help bring healthcare to 38.5 million people. Before investing in AI, the authorization process for GuideWell took an average of 1–2 weeks at times, leading to provider abrasion. The process also created confusion for patients and made it unclear what steps to take after a doctor's visit. Additionally, administrative staff who process these PAs experienced burnout because of the high number of requests and the cumbersome regulations for each request. Often, many of their PAs reflected conditions that were too complex and unique to address with generalized automation.

To address these challenges, GuideWell developed an AI solution for prior authorization designed to operate within the framework of a multi-payer platform called Availity. Over 41,000 of GuideWell’s providers already used Availity for various functions, including prior authorization requests. When providers submit an authorization request through Availity, an AI model guides the provider through a questionnaire. The tool, called Availity AuthAI, shows each user the criteria needed to meet medical necessity for the requested procedure. Submitters can also attach electronic medical records with the requests. After submission, the tool can automatically provide an approval recommendation for each submission in less than 90 seconds when the criteria are met. Availity AuthAI is currently applied to hip and knee procedures, musculoskeletal procedures, and advanced imaging requests, which represent the majority of authorization requests.

Here are the three steps GuideWell followed to evaluate, build, and implement this solution:

1. Used a holistic approach to choose a solution: GuideWell conducted a market landscape assessment to determine if there were innovative solutions that could streamline their prior authorization (PA) process or if they should build a solution internally. They also gathered input from various teams — customer experience, clinical, claims, IT, and finance — to ensure the chosen tool would improve patient outcomes, streamline operations, and be financially viable. Lastly, they integrated their existing technology prioritization process to make sure their solution aligned with their business goals and provider practices without major disruptions.

2. Prioritized the member and provider experience: A PA request can sometimes take upward of 14 days to process. By reducing processing time, GuideWell aimed to cut back on delays in patients receiving necessary medical care and increase transparency of treatment timelines. Additionally, clinicians often must handle a high volume of PA requests, some of which have unclear requirements for approval. Increasing efficiency in the PA process would make it easier for clinicians to meet this demand.

3. Emphasized training and education for end users: GuideWell placed a heavy emphasis on training and education protocols for providers. They sent out materials at intervals of 120 days, 90 days, and 60 days before the program started to educate and train providers on how to use the tool. They also leveraged their existing relationships and trust with providers, by using a team of dedicated provider relations specialists and a provider education team to facilitate the tool’s rollout. GuideWell conducted over 100 specific provider education sessions.

Since the program’s start, the Availity AuthAI tool has processed over two million PA requests. GuideWell reduced overall cycle time for PAs to an average of 11 hours, which is significantly below the industry standard. More importantly, GuideWell has noted positive feedback from providers, members, and internal teams. This shows an improvement in streamlining their PA workflow and reducing complexities.

Within just weeks of implementation, GuideWell removed ambiguity from member care by getting them an answer on requested procedures in real time. The tool resulted in 78% of approvals occurring via automation, with almost 76% occurring within 90 seconds. This has improved member experience and satisfaction, a key pillar of GuideWell’s mission.

GuideWell's journey in reshaping prior authorization with AI underscores the importance of innovation and boldness within healthcare organizations. Their key message for other leaders is to embrace the courage to seek out and implement groundbreaking solutions to long-standing challenges. By strategically investing in technology, organizations can distinguish themselves from the competition and emerge as pioneers in their sector.

Using AI in prior authorization can improve efficiency, patient satisfaction, and cost management. However, leaders will only recognize the full potential of AI if they coordinate their investments rather than confine them to separate silos within payer or provider spaces. Isolated investments lead to fragmented systems and missed opportunities for scaled impact. A collaborative approach to AI investment like the one implemented by GuideWell can unify payer and provider operations, creating a more cohesive, efficient, and patient-centered healthcare landscape. By pooling resources, knowledge, and technology, the healthcare industry can avoid redundancy, accelerate innovation, and drive more substantial improvements that benefit all stakeholders.