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Cohere Health Commends Unified Efforts for Prior Authorization Reform

Cohere Health®, recognized for its leadership in clinical intelligence solutions targeted towards health plans and risk-bearing providers, has recently expressed its support for the simultaneous announcements made by the American Health Insurance Plans (AHIP), the U.S. Department of Health and Human Services (HHS), and the Centers for Medicare & Medicaid Services (CMS). These organizations have outlined significant commitments aimed at overhauling the prior authorization (PA) process, an endeavor that is pivotal for improving efficiency within the healthcare delivery system.

The aligned pledges from major health insurance providers emphasize the reduction of administrative burdens, enhancement of transparency, and acceleration of access to necessary healthcare services. This concerted effort marks a significant advancement towards a more collaborative and effective healthcare system, where the resources can be redirected towards patient care rather than cumbersome administrative tasks.

In their announcements, the entities delineated specific, measurable goals that include:

• - Adoption of FHIR®-based APIs: This enables real-time decision-making for at least 80% of authorization requests that require clinical documentation.
• - Enhanced Communication: Strategies to boost clarity regarding decisions made regarding prior authorizations.
• - Reduction in Scope of Services: Narrowing the types of services that necessitate prior authorization.

Cohere Health is already making strides in meeting or surpassing these objectives through its innovative approaches across the nation. Some impressive metrics include:

• - Up to 85% of prior authorization approvals achieved nearly instantaneously.
• - 9 million authorizations processed using FHIR APIs within the last year.
• - A remarkable 61% decrease in time required for provider input.
• - Medical necessity reviews that are 50% quicker and boast over 99% precision through the use of sophisticated AI-enabled applications.
• - Ensuring that all clinical AI algorithms and final determinations involve board-certified physicians for 100% of relevant cases.
• - A high provider satisfaction rate of 93% from over 600,000 supported providers.

CEO and co-founder of Cohere Health, Siva Namasivayam, expressed, "Since 2019, we have been at the forefront of advocating for real-time prior authorization and improving the experience for both providers and patients via AI algorithms and FHIR API standards. The endorsement from CMS of this industry pledge signals a clear mandate for modernizing the prior authorization process. It reflects the essential transformation that the healthcare landscape needs, benefiting both patients and providers alike."

Transforming Prior Authorization Experience

The Cohere Unify™ platform, along with the company’s comprehensive Utilization Management Suite, integrates evidence-based clinical guidelines, expert medical review, and precision AI to revolutionize the prior authorization journey. This platform facilitates submissions from providers regardless of the interface used—be it electronic health records (EHRs), phone, fax, or online portals. Moreover, it operates with FHIR-based electronic prior authorizations (ePA), making the submission process more streamlined and the decision-making process significantly faster.

The platform goes further by providing real-time, context-sensitive guidance aimed at ensuring the completeness of requests right at the point of submission. A dynamic clinical rules engine adapts to various care contexts—whether preventive, episodic, or emergency—while remaining consistently updated through continuous contributions from board-certified physicians. For providers with strong approval histories, personalized workflows through Cohere Align™ enhance their experience. Unlike traditional gold carding processes that may neglect reviews, Cohere’s methodology retains clinical oversight without sacrificing workflow efficiency for providers who consistently perform well.

AI-Powered Precision and Clinical Oversight

Cohere’s AI technology is strategically designed to bolster and hasten approvals and is never utilized to deny care. Non-approved requests are subjected to thorough reviews conducted by licensed medical professionals, ensuring a balance of speed and accuracy. The platform's decision-making models are meticulously trained on both structured and unstructured clinical data, enhancing support for decisions based on individual patient details and the nuances of real-world practice.

Recent surveys conducted by Cohere involving 100 clinicians and 100 administrative professionals associated with prior authorizations showed a unanimous trust in AI technologies—99% of clinicians and 96% of administrators expressed confidence when AI is properly applied in the PA decision-making process. Cohere's Medical Advisory Board and clinical strategy teams maintain rigorous oversight of its decision-making algorithms to assure that technology remains a supportive tool—one that complements rather than supplants provider judgment.

Continued Evolution and Improvement

Despite the complexity associated with prior authorization, whereby questions of medical necessity and patient safety often present recurring challenges, Cohere seeks to aid health plans in refining this process, particularly in areas with significant clinical variability. The platform diligently records data throughout the entire authorization cycle, pinpointing friction points like duplicated submissions and avoidable denials. Such insights empower health plans to determine which clinical codes truly necessitate prior authorization while progressively adjusting policies and optimizing processes to improve efficiency, enhance provider experiences, and ensure patient safety.

As the healthcare ecosystem embarks on a transformative phase of prior authorization reform, Cohere Health is already witnessing tangible outcomes that align with the goals outlined by CMS and AHIP member plans. The firm remains resolutely committed to fostering a more efficient, transparent, and equitable healthcare landscape for patients, providers, and health plans alike.

For further information, visit Cohere Health.