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Cohere Health Announces National Expansion of Humana Partnership to Transform Prior Authorization Process

Strong results from new digital prior authorization platform drive expansion from 12 to 50 states

Cohere Health, an emerging high-growth digital health company, announced that Humana Inc. is embarking on a nationwide expansion of Cohere’s digital authorization platform for musculoskeletal (MSK) services, based on the success of its initial implementation. After rolling out the platform across 12 states in January 2021, Humana has made significant progress toward achieving its vision to reimagine and modernize processes for prior authorization by reducing approval times, increasing provider satisfaction, and improving delivery of care, all while preserving important benefits such as safety, predictability, and reducing waste.

PREDICTIONS-SERIES-2022In the currently implemented 12 states, 95% of authorization requests for MSK services now flow through Cohere’s digital platform. By greatly reducing the need for manual clinical review, Cohere’s digital authorization platform drives a median approval time of 0 minutes, enabling Humana providers to schedule patients for the requested service immediately in 89% of cases.1 The upcoming expansion will extend the platform’s value to all Humana Medicare Advantage and Commercial members nationally, and to more than 65,000 individual practitioners representing more than 10,000 physician practices.

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Cohere’s digital health plan solutions transform prior authorization processes to drive collaborative care journeys, thereby enabling truly touchless authorization. The Cohere platform automates both provider and payer steps in the process, while also coupling AI and machine learning with evidence-based clinical policy to support better care decisions. For MSK care delivery, Cohere’s clinical criteria are informed by policies established by the American Academy of Orthopedic Surgeons (AAOS). Cohere uses the point of authorization approval as a trigger to engage plans, providers, and patients in transparent, episode-based care paths more than 65% of the time.2 These care paths merge traditional utilization management, care management, and patient engagement functions, and make evidence-based policy and recommendations completely transparent to the requesting provider.

“In just nine months, the results of Cohere’s digital authorization platform have exceeded our expectations,” said William Shrank, MD, MSHS, Chief Medical Officer at Humana. “When we got started we were looking for industry-leading electronic adoption, best-in-class physician experience, demonstrably better patient experiences, compelling medical and administrative return on investment, and rapid innovation. What is exciting is that these results reflect just the beginning. We look forward to reaching even farther and offering these results to more of our members and network partners.”

As the industry moves toward more value-based arrangements and risk-bearing payment models, the platform’s national deployment will help Humana better manage utilization by enabling technology-driven collaboration between Humana, its providers, and members.

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Providers have reported high satisfaction with Cohere’s platform, with 72% indicating they are “very satisfied” and 68% indicating that the Cohere platform is “much easier” to use than alternative solutions. Overall provider net promoter scores (NPS) have increased more than 100% since the platform was implemented in January.

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Beyond processing the authorization request itself, the platform uses evidence-based, technology-driven recommendations for alternative services and care sites, which further improves care quality and timing.  For example, Cohere’s solution successfully influences providers to switch from an inpatient to an outpatient setting, when warranted by the evidence, in 65% of cases.4 This same technology enables high-performing providers to follow a faster prior authorization request process, while also helping case managers to rapidly prioritize and process cases that require manual review.

“Our platform is designed to treat the ordering physician as a partner, engaging them with evidence-based suggestions that are transparent and helpful. This allows health plans to focus their resources on just the high-impact cases that require manual expert review. As a result, the health industry can handle a much greater volume of authorizations with fewer resources,” said Brian Covino, M.D., Chief Medical Officer at Cohere Health. “Front-line physicians benefit from significant decreases in prior authorization administrative cost and effort, along with far less need for time-consuming peer-to-peer conversations and appeals. Along with the platform’s ease of use, these benefits are why our provider adoption is industry-best.”

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[To share your insights with us, please write to sghosh@martechseries.com]

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