Humana will partner with Cohere Health in an effort to streamline prior authorization for musculoskeletal treatments across 12 states.
Cohere's platform allows for prior authorization approval for the entire episode of care, instead of requiring such approvals at each step. The member will be preapproved for services from the initial diagnosis through their return to health, which allows physicians to tailor treatment plans to the individual and avoid waits for approval during the treatment process.
Humana will use the platform in Alabama, Georgia, Indiana, Kentucky, Michigan, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia and West Virginia beginning Jan. 1.
That encompasses about 2 million members and 3,500 physician practices, the insurer said in an announcement.
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William Shrank, M.D., chief medical officer at Humana, told Fierce Healthcare that while prior authorization is a key tool insurers can use to ensure the right care is being delivered to the right patient, there is plenty of room to make the process easier and simpler for providers.
"It is a real pain point for doctors. It is a source of friction and uncertainty for patients," he said, "and it is an area that health plans realize, with humility, that there are ways that we can do better."
Cohere's Next platform initially focuses on musculoskeletal services as there are clear, evidence-based guidelines to work from for prior authorization, and the services account for high amounts of spending, Siva Namasivayam, Cohere's CEO, told Fierce Healthcare.
In addition, because there are often a number of smaller steps on the way to, for example, a knee replacement, there often are high numbers of prior authorization checkpoints in tandem, he said.
"All of this kind of made it a really interesting first area to focus on," Namasivayam said.
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The goal is to make the process a "straight line" from diagnosis to recovery for the patient, he said, and examine their journeys in an end-to-end way to cut out unnecessary delays and steps.
Shrank said the platform is a useful tool in advancing value-based care. For Humana's provider partners in value-based arrangements where they take on significant risk, the insurer essentially turns off prior authorizations, he said.
However, these providers will request that they deploy these utilization management tools anyway to avoid wasteful spending and drive toward more high-value treatment options.
"In a setting where there’s providers delivering value-based care, having a more automated and simple solution that still really focuses on driving evidence-based-guideline-driven care is a win-win for the provider and for the patient," Shrank said.