Imagine assembling a complex piece of furniture. You have the instructions, but sometimes, you overlook a crucial step. Now imagine if the instructions were interactive, providing recommendations and highlighting any items you might have missed at each step.
In the same way, Cohere’s AI-powered nudges guide providers, helping them navigate the complex prior authorization (PA) process with precision and assisting them in completing every step correctly. These nudges are like the blueprints for a well-constructed workflow, providing real-time guidance that avoids back-and-forth requests, speeds up the authorization process, and reduces provider burden.
The administrative burden of prior authorization
Prior auth has traditionally felt like building something complex without the right tools or guidance. However, with Cohere’s AI-powered nudges, health plans can significantly improve the process for providers and patients.
According to the American Medical Association (AMA), 35% of physicians have full-time staff dedicated solely to handling PA requests, and each physician submits an average of 43 authorization requests per week. Providers using Cohere’s intake portal reported an 85% improvement in turnaround time (TAT), and 93% expressed satisfaction with their PA process.*
Cohere’s blueprint for prior auth
Cohere optimizes the prior authorization process through real-time, AI-powered nudges that guide providers at every step. These nudges act like instructions, helping ensure that every piece of the process is in place before the request is even submitted.
1. Administrative nudges:
Administrative nudges function like step-by-step blueprints for assembling furniture, guiding providers to include all necessary information and attachments before submitting an authorization request. By catching these issues upfront, nudges catch issues early, reducing submission errors and increasing the likelihood of auto-approval.
This speeds up the process and eliminates unnecessary delays. Instead of scrambling to find missing documentation or dealing with resubmissions, providers receive real-time alerts about missing attachments or clinical details, allowing them to address issues before submission. This preemptive guidance strengthens the process, preventing costly delays later on.
2. Clinical nudges:
Once the administrative side of the process is streamlined, clinical nudges act as a guide to ensure that the requested care aligns with best practices and cost-effective options. These nudges leverage AI and machine learning to analyze the patient’s clinical data, comparing it to recommend evidence-based care alternatives. For example, a clinical nudge might suggest that a procedure be shifted from an inpatient setting to an outpatient facility, offering the same quality of care at a lower cost.
Clinical nudges for better value
Cohere improves the PA process and enhances care pathways by helping providers drive their patients toward the most appropriate, cost-effective treatments.
Let’s look at an example:
After analyzing claims data, Cohere’s AI technology identified patients with similar profiles who had successfully undergone osteoporosis screenings and fracture care management in a primary care setting. Based on this, it deployed a nudge, recommending that the patient receive the necessary screening and follow-up care in a more cost-effective outpatient setting rather than a higher-cost hospital environment.
By shifting the procedure to an outpatient setting, the system triggered an auto-approval to accelerate the entire authorization process and avoid unnecessary delays.
Building a better future for prior auth
AI-powered nudges represent a fundamental shift in conducting prior auth and utilization management (UM) processes.
By guiding providers through the plan’s process, Cohere is:
- Alleviating administrative burden for providers
- Improving collaboration between health plans and providers
- Speeding up patient access to the right care
- Reducing unnecessary steps and costs by guiding providers to more appropriate, evidence-based care options
As healthcare evolves, AI-powered nudges will be pivotal in making the PA process faster, more efficient, and ultimately more patient-centered. With CMS regulations on the horizon, health plans must implement tools for turnaround times, transparency, and administrative efficiency standards to meet the new regulations.
Curious how AI-driven nudges can transform your prior authorization process? Learn more through our dedicated demo.
*based on Cohere Health data as of Q2 2024.
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About the Author: Cohere Health
