Last month, Cohere Health was reaccredited by the National Committee for Quality Assurance (NCQA) in Utilization Management for ensuring appropriate patient care and following evidence-based best practices.

NCQA utilization management (UM) accreditation ensures that patients have the proper care and the required services without overusing resources. Additionally, the reaccreditation guarantees that Cohere follows objective, evidence-based best practices when making decisions and conforms to the industry’s highest standards.

Setting the bar for quality in intelligent prior authorization

In July 2021, Cohere became the first intelligent prior authorization platform to receive NCQA accreditation. Achieving NCQA accreditation remains a testament to Cohere’s ability to drive quality care by reducing the burden and friction that the prior authorization process has traditionally brought on for health plans, providers, and patients.

In the wake of the Centers for Medicare & Medicaid Services (CMS) passing its prior authorization final rule–which will improve interoperability, turnaround times, transparency, and accountability–health plans are swiftly preparing to comply with the rule’s prior authorization provisions. Intelligent prior authorization platforms that support regulatory compliance, like Cohere’s, must ensure quality standards are met.

The most prominent health plans in the country are NCQA accredited, and an NCQA Utilization Management Accreditation helps ensure that organizations make clinically appropriate decisions for patients anchored on objective, evidence-based best practices.

“Achieving NCQA Utilization Management Accreditation demonstrates that Cohere Health has the systems, process, and personnel in place to conduct utilization management in accordance with the strictest quality standards of the Utilization Management Accreditation Program,” said Margaret E. O’Kane, President, NCQA.

Building a cybersecurity framework

Using objective, evidence-based criteria, NCQA evaluated Cohere’s intelligent prior authorization platform to make fair and timely determinations (on behalf of our health plan clients) about the appropriateness of services. The UM accreditation provides a quality improvement framework for implementing industry best practices to ensure:

  • Fair and timely utilization evaluations using objective, evidence-based criteria: 
    • Collection and use of relevant clinical information to make utilization management decisions
    • Qualified health professionals assess requests and make utilization management decisions
  • Alignment with state requirements
Our impact

Cohere’s intelligent prior authorization platform processes over 5.6 million requests annually, positively impacting more than 15 million health plan members and 457,000 healthcare providers nationwide.

To date, Cohere’s intelligent prior authorization platform has:

  • Enabled 70% faster access to appropriate care (roughly equivalent to five days) for patients
  • Saved 38,600 clinical review hours annually for a single health plan client
  • Automatically and instantly approved up to 80% of prior authorization requests
  • Achieved an industry-leading 90% platform adoption by providers of our digital solution versus fax and other manual methods to submit a prior authorization, along with a 91% satisfaction rate among providers utilizing the platform

Currently, Cohere’s solutions are utilized by several major health plan clients nationwide, including Humana, Geisinger, and Medical Mutual.

About NCQA

NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of healthcare organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. NCQA’s website (ncqa.org) contains information to help consumers, employers and others make more informed health care choices.

NCQA can be found online at ncqa.org, Twitter, Facebook, and on LinkedIn.

Published On: June 13th, 2024Categories: Blog

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About the Author: Meghan Davis, R.N.

Meghan Davis, RN, serves as a Senior Compliance Auditor at Cohere Health. In this role, Meghan leverages her extensive nursing experience to conduct internal manual review audits, collaborate across all departments, assist in staff education and training. In this capacity, she actively led the NCQA re-accreditation process, highlighting her expertise in healthcare compliance and quality assurance. Previously, she served as a registered nurse for nearly 10 years at UVA Health.