Medicare beneficiaries now have access to an average of 43 health plans—more than ever. As competition heats up in the health plan market, Star Ratings become increasingly critical. Intelligent prior authorization is one lever to improve Star Ratings across five key areas: patient care access, high-quality healthcare, care coordination, health plan and provider quality, and outcomes for complex populations.

Medicare members use CMS star ratings to assess the quality, benefits, and costs of available health plans

The Centers for Medicare & Medicaid Services (CMS) publish the Medicare Advantage (Medicare Part C) and Medicare Part D Star Ratings each year. Star Ratings measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans).

The Star Ratings system helps Medicare consumers compare the quality of Medicare health and drug plans and empowers them to make the best healthcare decisions. Consumers rely on Star Ratings to provide information to assess the quality, benefits, and costs of available health plans. It helps Medicare members and their caregivers be informed and active healthcare consumers.

As of 2023, 30.8 million people are enrolled in a Medicare Advantage plan, accounting for more than half of the eligible Medicare population, and $454 billion (or 54%) of total federal Medicare spending. The average Medicare beneficiary in 2023 has access to 43 Medicare Advantage plans, the greatest number of options ever.

Star ratings also impact the premiums Medicare Advantage plans receive. Higher premiums allow for increased and higher quality benefits for members, which enable member retention and health. This virtuous cycle is an important one for health plans, which intelligent prior authorization can support.

Five ways intelligent prior authorization can help improve and maintain Star Ratings

Intelligent prior authorization uses artificial intelligence (AI) and machine learning to streamline prior authorization workflows and improve quality and patient outcomes. With higher star ratings dependent on how health plans address various patient needs, forward-thinking health plans can utilize this advanced technology to improve care quality in five key areas.

1. Enabling swift patient care access with automated prior authorization decisioning

Ninety-four percent of physicians report that prior authorization has contributed to delays in care access. Due to its highly manual nature, it can take up to two weeks to receive authorization for nonurgent medical services. This delay contributes to the overall length of the care episode, frustrating both patients and physicians.

Intelligent prior authorization uses a combination of optical character recognition (OCR) and machine learning to extract relevant information from clinical notes and historical patient data and automatically approve most prior authorization requests without the need for clinical assessment questions to providers. As a result, patients receive appropriate care faster and clinical staff save time, so they can work efficiently and focus on patient care.

Episodic authorizations use a triggering high-profile event (like a surgery) to consolidate multiple related services within a discrete care episode. Health plans can reduce the administrative burden associated with separate prior authorization requests for this collection of services and tighten the care episode for the patient by requiring only one authorization for multiple services.

2. Driving optimal outcomes across the entire care journey with a care path approach

A care path is a recommended sequence of medical services, generated by a combination of AI, population health data, and evidence-based clinical criteria. Health plans that use a care path approach collaborate with providers to drive patient-specific care pathways that support the best outcome for diagnoses. Cohere’s care paths are developed in partnership with leading national specialty organizations, such as AAOS and ACC. Through care paths, health plans leverage AI to go beyond UM, and treat prior authorization transactions as triggers to improve the end-to-end patient journey.

3. Accelerating care coordination with interoperability and transparency

Digitized intake across multiple channels helps improve interoperability. Whether requests are submitted via fax or through the EMR, a digital front door collates clinical information across platforms and digitizes it for sharing across stakeholders and automated decisioning, getting patients the right care faster.

Breaking down the barriers to information sharing in prior authorization makes it instantly clear to providers which services require authorizations and what clinical evidence is needed, enabling a much higher instance of immediate approval.

As a company on the cutting edge of advanced technology application in the prior authorization space, Cohere has encouraged the adoption of Da Vinci standards with its health plan partners since its founding, which break up the prior authorization transaction into three standards:

• • Coverage Requirements Discovery (CRD) allows for real-time determination of prior authorization requirements
  • Prior Authorization Support (PAS) allows providers to submit prior authorizations via interoperable, electronic means
  • Documentation Templates and Rules (DTR) allow providers to see in real-time the documentation requirements and if they are fulfilled

Health plans that use Da Vinci standards provide more context to prior authorization decisions, enable an easier glidepath to integration, and facilitate transparency with their provider partners.

4. Leveraging high-quality providers more consistently with provider intelligence reporting and analytics

Digitization of prior authorization additionally enables health plans to drive value through their top-performing services and providers. Cohere regularly analyzes utilization data, prior authorization historical data, and subsequent patient outcomes to help health plans identify the best sequence of care and influence care upstream. Cohere delivers scorecards to ensure providers and health plans have insight into their performance and actionable recommendations for how they can continually improve and deliver better care.

5. Facilitating greater impact of care management programs using automatic triggers within the prior authorization process

Treatment of osteoporosis in women is one area that CMS includes directly in its Star Ratings evaluation. Cohere echoes CMS’s focus on osteoporosis and delivers a fragility program using advanced technological capabilities to improve outcomes for this target population. Patients with a high risk of developing osteoporosis are often not risk-stratified or screened properly: of the 54 million Americans age 50 and over who are at risk of osteoporosis, only 9% have received a bone mass density test.

In-workflow nudges leverage the prior authorization process to educate primary care physicians on early indicators of osteoporosis. During a relevant prior authorization request, such as for kyphoplasty or vertebroplasty, Cohere’s technology identifies at-risk patients that primary care physicians should consider for osteoporosis screening. This early intervention helps improve care for this at-risk population and reduce medical expense.

Health plans interested in improving care quality for their members and improving their Star Ratings leverage intelligent prior authorization as a trigger to encourage patient care access, high-quality healthcare, care coordination, health plan and provider quality, and better outcomes for complex populations.

Discover how your health plan can improve its Star Ratings with our care path approach.