Cohere Health advises federal government on proposed prior authorization and interoperability reform

Background on the rule
In December 2022, The Centers for Medicare & Medicaid Services (CMS) made headlines with a new proposed rule, Advancing Interoperability and Improving Prior Authorization Processes (CMS-0057-P).

The goal: streamline and automate the historically burdensome prior authorization (PA) process; improve interoperability and transparency; and, ultimately, ensure patients get the care they need, when they need it.

The time for prior authorization reform is now. The numbers illuminate why: in the American Medical Association (AMA)’s 2021 prior authorization survey, 91% of surveyed physicians reported that authorizations negatively impacted their patients’ clinical outcomes, and 88% described the burden associated with PA as high or extremely high. Lawmakers have acknowledged the growing call for change and are quickly introducing policies at both the state and federal levels.

Cohere Health applauds the agency for its efforts to reform prior authorization, and for continuing upon the previous administration’s work to drive change in the space. Though the 2020 rule is now withdrawn, the same subject matter experts authored the new rule. Moreover, the new rule would also apply to Medicare (which was omitted from the previous rule) and includes four specific prior authorization provisions. To learn more, I broke down the four things you need to know about the rule and the prior authorization-specific policies.

Before the provisions go into effect on January 1, 2026, CMS is taking public comments to help mold the final version of the rule with critical input and recommendations from stakeholders, thought leaders, and policymakers in the space. As recognized leaders of intelligent prior authorization, Cohere is pleased to submit public comments to CMS, as we have done previously for the Office of the National Coordinator for Health IT (ONC)’s request for information (RFI) on electronic prior authorization standards.

We encourage you to read our full letter to CMS, and explore our comments below on one of the key provisions, Improving Prior Authorization Processes.

Provision 1: Prior Authorization Requirements, Documentation and Decision (PARDD) API

• Under the new rule, payers will need to build and maintain a Fast Healthcare Interoperability Resources (FHIR) application programming interface (API) (PARDD API) that automates the process for providers to determine prior authorization requirements, documentation, and decision guidelines. The API aims to reduce providers’ PA burden and ensure patients, providers, and health plans can all access the appropriate information to make informed, efficient care decisions. Cohere is supportive of this policy.

• Cohere is unwaveringly focused on automating the prior authorization process. Our intelligent prior authorization solution digitizes authorization intake across all channels (such as fax, web portals, and the EHR) to unify previously siloed health data, allowing payers to move forward with automated decisioning, decreased administrative burden, faster access to care, and greater interoperability.
  

Provision 2: Denial Reason

• Impacted payers will need to include a specific reason when denying a prior authorization request to facilitate better communication and understanding between the payer and provider and, if necessary, a successful resubmission of the authorization request. Cohere is supportive of this policy.

• This level of transparency for patients and their caregivers is important. Transparency allows them to be involved in the prior authorization process and gives them newfound insight into their care journey. Today, our platform provides specific reasons for denials, and we publish our decision and care path guidelines for users. This ensures all required criteria can be met before an authorization is even submitted, thus decreasing the friction often felt between payers and providers and speeding up the time to decision.

Provision 3: Prior Authorization Time Frames

• Impacted payers will need to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests. Cohere supports the policy to require faster turnaround times (TAT) for prior authorization decisions, and we encourage CMS to consider placing requirements on the proportion of prior authorization requests that are automatically adjudicated.

• We believe that at least 60-70% of authorization requests should be instantaneously adjudicated. In the AMA study cited above, 93% of the physicians surveyed reported care delays associated with prior authorization. Now, we have the critical opportunity to shape policy that better sets up patients and their providers for success. What’s more, new TAT requirements can serve as a driver for decreasing provider burden. Forward-thinking payers are already investing in intelligent technology that automates prior authorization processes and decisioning, thus reducing the burdensome, time-consuming workload of tasks like manual reviews and locating missing information, and in turn, getting patients the care they need sooner.

• CMS also sought feedback on “gold carding” programs that relax or reduce prior authorization requirements for providers demonstrating consistent compliance. Cohere believes that, while well-intended, gold carding can potentially increase authorization complexity, effectively hindering one of payers’ important tools for impacting value and quality. We recognize the key role providers play in interoperability and are concerned that manual processes will persist if the use of new technology isn’t incentivized more. One way to incentivize providers is to reward high-performing physicians via “green lighting,” which affords them reduced admin burden and even faster authorizations where clinically appropriate. Once providers implement these new capabilities into their workflows, we’ve observed that providers consistently use electronic prior authorization systems.

Provision 4: Prior Authorization Metrics

• Impacted payers will need to publicly report certain prior authorization metrics by posting them directly on their website or via publicly accessible hyperlink(s) annually. Cohere is supportive of this policy.

• Cohere is supportive of the push for greater transparency in the care delivery system and prior authorization processes. We actively facilitate this type of transparency between health plans and their provider networks. Today, we deliver scorecards on a quarterly basis to our health plan partners. This is an important step to ensuring providers and health plans have insight into their performance and how they can continually improve and deliver better care.

• There are, however, prior authorization technology vendors prohibiting other vendors from embedding their licensed content. We believe this refusal is monopolistic and creates an unfair market advantage. Most importantly, the refusal of these vendors to comply limits payer and provider choices in how they comply with CMS regulations. We urge the agency to consider this unforeseen consequence when considering pushback against transparency around prior authorization metrics.

Next steps for compliance

We thank CMS for the opportunity to comment on the proposed rule. We’re committed to supporting a policy environment that is favorable to an interoperable healthcare system, which is critical to achieving a streamlined prior authorization process and, ultimately, better, faster, and more valuable patient outcomes.

Given the importance of data exchange and interoperability to the success of electronic prior authorization, we recognize CMS’s important role in these efforts as it seeks to develop standards for these programs and look forward to further engaging with the agency on this work. We’re actively participating in the health policy conversation around prior authorization at all levels of government: we’ve met with congressional staff, CMS, ONC, and other key agencies, and have offered to be technical resources for those agencies focused on prior authorization reform. We look forward to keeping our current and future partners abreast of these efforts and discussing how we can best support them in this time of transition.

The rule will be implemented in 2026, so payers must start addressing these process changes now to be suitably prepared to comply when it goes into effect.

And we want to help.

Cohere’s platform already meets–and in most cases, exceeds–the forthcoming requirements proposed by CMS. Intelligent prior authorization can truly serve as a strategic lever for better payer-provider collaboration, interoperability, transparency, and patient care.