Q&A with Siva Namasivayam of Cohere Health: The role of prior authorization in a holistic approach to care 

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AVIA Marketplace is the leading online resource for accurate, unbiased information about digital health companies and solutions. Our goal: To empower hospitals and health systems with the information they need to match with vendors who can meet their unique needs. We asked the top companies in the prior authorization space about their solutions and what they think the future of digital health looks like. No sponsored content or advertorials—just transparency and insights that decision-makers can use. 

Cohere Health’s intelligent prior authorization solution is configurable to the needs of individual health plans, and can be implemented as a licensed platform (Cohere Unify™) or as a fully outsourced utilization management service (Cohere Complete™). Cohere’s solutions enable end-to-end automation of prior authorization that not only digitizes the process, but adds a layer of clinical intelligence that nets administrative efficiencies for payers and providers and better outcomes for patients. With a customizable methodology, Cohere’s solutions improve provider experiences, reduce administrative burden, and drive more automated real-time decisions with accelerated clinical review while smoothly integrating into provider and health plan system’s prior authorization workflows.

CEO Siva Namasivayam is a technology and healthcare veteran with over 20 years of experience utilizing technology and data to improve healthcare processes. Prior to co-founding Cohere, Namasivayam was a founding partner of SCIO Health Analytics, which served over 50 Fortune 500 healthcare organizations. He holds a master’s degree in computer science from the University of Pittsburgh, as well as an MBA from the University of Michigan.

Q: Can you tell us about your company and the challenges you are solving within the prior authorization space?

A: Prior authorization, or PA, remains a massive administrative burden for health plans and their provider partners, and often delays patient care. It also represents an untapped opportunity to improve patient care journeys and enable more successful value-based care arrangements.

The Cohere Unify™ solution suite automates prior authorization intake and decisioning to drive administrative efficiency, while adding clinical intelligence to speed and improve patient outcomes.

Our intelligent prior authorization solutions leverage an innovative blend of AI and machine learning, clinical expertise, and real-time analytics to shift the framing of prior authorization and concurrent review from transactional to transformational. By orienting service requests within the context of the broader patient journey and applying learning from health plan data, health plans can leverage utilization management to improve the provider experience and patient access to quality care.

In addition to reducing administrative time, cost, and abrasion, our solutions offer these capabilities:

  • Care path generation, to enable collaboration on a patient-specific treatment plan designed to produce the best and fastest outcome.
  • Pre-submission influence, to help guide optimal care choices before requests are submitted, such as shifting site-of-service.
  • Episode-based authorization, to leverage care path technology to approve an entire set of services upfront.
Q: How does your company differentiate from other vendors in the same category?

A: Cohere Unify™ intelligent prior authorization solutions enable end-to-end automation of prior authorization with digitization and the addition of clinical intelligence. As a result, our client health plans achieve significant administrative savings and better, more efficient patient outcomes.

Cohere’s differentiators impact patients, providers, and health plans alike:

  • Faster, better patient outcomes
    • Patient-specific reviews
    • Pre-submission influence

  • Less abrasive provider experiences
    • Request consolidation
    • Accuracy assurance
    • Immediate processing

  • More efficient, less costly health plan operations
    • Automated plan policy
    • Manual review pre-processing
    • Real-time analytics

Q: What are some of the biggest changes your company has seen around how health systems are approaching prior authorization, given the changes in the landscape over the past couple of years?

A: The process of securing advance approval from a health plan for a test, medication, or surgical procedure is often problematic for physicians and their patients. Prior authorization is still a largely manual process, which requires providers to fax forms and clinical notes to multiple health plans, each with its own authorization processes and coverage policies.

Over the past five years, the push to mandate the implementation of electronic PA has gained new traction through state and federal legislative efforts. Members of the 117th U.S. House of Representatives passed legislation that would affect the future of PA for Medicare Advantage (MA) plans. The Improving Seniors’ Timely Access to Care Act was intended to reduce providers’ administrative burden while improving the speed of patient access to necessary care.

In December 2021, The Centers for Medicare & Medicaid Services (CMS) proposed a new rule to advance interoperability and improve prior authorization for Medicare and Medicaid patients. CMS’ new rule includes public feedback from a former iteration of the rule, proposed back in December 2020 and would place new requirements on Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans and CHIP managed care entities, and qualified health plan issuers on federally facilitated exchanges. 

Electronic PA is a good start, but it is not enough. To have a significant impact on the cost and quality of care, health plans must adopt intelligent technology that gives providers meaningful support to help achieve the fastest and best possible outcomes for patients.Cohere’s intelligent authorization solutions can easily exceed the legislative requirements for greater automation, transparency, and accelerated approvals by utilizing evidence-based clinical criteria that are clearly defined and referenceable for physicians. Improved transparency and interoperability can reduce the friction between health plans and their provider partners. Prior authorization facilitates this communication, making it clear which services require approval, what documentation is necessary, and citing national medical society’s standards of care encouraging physicians to follow a high-value recommendation for a particular site, service, or test.

MA plans are committed to improving clinical outcomes and provide members with access to the most appropriate health care services. To that end, MA plans should adopt broader perspectives on utilization management in order to better serve their members and allow PA to function as a benefit instead of a roadblock.

Q: What does an ideal client look like? How are health systems or health plans best organized for success in standing up prior authorization and adjacent capabilities?

A: Health plans are facing increased pressure from providers, regulatory institutions and patients to fix the problems associated with prior authorization. Since utilization management solves an unavoidable problem, health plans should instead leverage utilization management as an asset to improve care delivery. By using advanced technology to leverage health plan data, our solutions transform the transactional process to a longitudinal one.

When physicians and health plans consider individual services within the context of care paths, they can align around longitudinal, quality care that is evidence-based and patient-specific. Solutions that harness health plan data and incorporate it with up-to-date clinical guidelines can leverage prior authorization as a tool to decrease care variation and drive medical expense savings. With this stronger focus on quality, health plans can respond to pressures and more effectively align themselves with value-based care models.

Q: What measurable outcomes have you seen from your clients?

A: Cohere Health serves more than 15 million members, and our intelligent prior authorization platform is used by more than 197,000 providers across all 50 states to submit and manage authorization requests.

Cohere delivers incremental medical cost savings while reducing denial rates by 63 percent. That’s because 64 percent of our impact on utilization comes from non-denial techniques, such as “nudges,” which promote appropriate care choices before the authorization request is submitted. Thanks to this unique approach, our process drives higher provider satisfaction, as represented by a very high net promoter score (NPS) of 55. In addition, 96 percent of the prior authorizations are submitted digitally through our platform, and patient access to care is expedited by 70 percent.

Q: What major functional enhancements and/or product investments are you making in the near term to keep up with the evolution of automation generally?

A: Recently, state and federal regulators moved forward with legislation to standardize the prior authorization process and reduce provider burden, including the implementation of gold carding efforts. Gold carding takes a provider’s authorization history for certain services and, if it meets a certain percentage approval threshold, exempts them from authorization requirements for those services going forward. But legislative efforts like gold carding are not enough on their own to address the challenges of prior authorization. Health plans require advanced solutions to provide the technological scaffolding to comply with legislation and truly transform utilization management.

The Cohere Unify™ platform has a more comprehensive capability than gold carding: green lighting. Green lighting goes beyond clinical assessment question modification and instead rewards high-performing providers. Using machine learning, green lighting predicts providers’ actions and decisions to simplify the authorization process without compromising the approval and delivery of evidence-based quality care. The green lighting approach allows health plans to meet compliance requirements for gold carding and move to a more advanced standard of care. Green lighting can link authorization decisions to provider tiers to programmatically implement gold carding requirements.

Beyond the regulatory landscape, intelligent prior authorization uses clinical nudges to deliver better care quality for patients. By looking at the longitudinal patient record, technology can collate authorization history for patient cohorts to be measured against general population health data and use it to inform these nudges. Clinical nudges can be used to suggest low-cost, high-performing care alternatives and other services that may be eligible for auto-determining, and streamline the authorization process to promote quicker access to quality care.

Q: How do you see the prior authorization space evolving in the next two to five years and beyond?

A: This next generation of intelligent prior authorization is the first step toward the transition to value-based care, in which a service request is oriented within a larger care journey and its ability to impact the patient’s overall health. By uniting providers around the common goal of providing value and better patient health outcomes, value-based systems create healthy competition in the healthcare space and drive down medical costs.

Health plans that use intelligent prior authorization leverage patient, provider, and regional population data to orient prior authorization service requests within each member’s care journey. These health plans are much better positioned to face this changing landscape. Machine learning that suggests clinically optimal care and accounts for social determinants of health, combined with prior authorization and intelligent decisioning, can help shift the focus away from single service requests and toward a more holistic approach to patient care.

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