Geisinger Health Plan and software company Cohere Health are teaming up to simplify the prior authorization process and reduce provider burden.
Through the deal, Danville, Pennsylvania-based Geisinger is licensing Cohere’s AI-driven utilization management technology and services platform, designed to support value-based care delivery. In the value-based care delivery model, providers are paid based on the health outcomes of their patients and the quality of their services.
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In a statement, Cohere said that its technology is designed to streamline the prior authorization process and support value-based care delivery while also reducing administrative costs. Cohere also aims to transform Geisinger’s utilization management overall to provide quality improvement initiatives across all lines of the integrated health system’s businesses.
The prior authorization process is used by health insurance companies to determine if they will cover a certain procedure or service. It is one of the most burdensome aspects of getting care approved for patients ahead of time and often leads to patients waiting for care.
Boston-based Cohere’s platform aims to make this process more efficient and less burdensome. One way it does so is by providing physicians with care paths based on the history of a Geisinger health plan member and his or her care needs.
The platform takes data from various sources — including claims data, clinical data from electronic health records and CMS datasets — to find populations with similar clinical characteristics. It then allows providers to compare different treatment plans based on these populations. These recommendations encourage providers to choose high-value options before they submit requests to the payer for a prior authorization.
Physicians can submit one bundled authorization for the patient’s entire care process — including imaging and diagnostics, surgery, medication, physical therapy and rehabilitation — rather than multiple, disjointed requests.
The hope is that for a majority of cases, patients don’t have to wait for prior authorization approvals. Cohere’s platform has a median approval time of less than a minute, according to the company. This process aims to reduce peer-to-peer clinical reviews and denials, and require less administrative work for physicians and health plans.
Geisinger Health Plan, which covers more than half a million members throughout Pennsylvania, isn’t Cohere’s only payer customer. Humana also uses Cohere’s technology since 2021 and its technology is being used in all 50 states. Humana’s providers have been able to immediately schedule patients for services in 89% of cases, according to a news release. When asked what it charges for services, Cohere declined to state its pricing structure.
Cohere claims that its platform creates 15% incremental medical savings on average and reduces denial rates by 63%. More than 95% of provider customers use its platform for the electronic submission and approval of prior authorization requests, and the platform accelerates care to patients by 70%. Surgical complication rates have decreased by 18% from the platform, according to Cohere.
“We’re excited not only to significantly improve the prior authorization process, but also to drive better care experiences and outcomes for our providers and members,” said John Bulger, chief medical officer for Geisinger Health Plan, said in the news release. “Cohere’s collaborative platform enables us to further differentiate our value-based care offerings, as our network providers can use the platform’s evidence-based, proactive care suggestions to make better health easier and ensure our patients receive optimal care specific to their medical history and condition.”
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