There are many problems with prior authorization (PA) as it stands: its fractured nature, obscurity around both documentation requirements and evidence-based guidelines, and overreliance on legacy channels have made it infamous in the world of healthcare. Worst of all, these pain points lead to potentially harmful care delays and fray the payer-provider relationship.

With this in mind, Humana and Cohere Health set out to make a change. Instead of treating prior authorization as a stumbling block, we seized on it as a unique point for patients, providers, and payers to align on care via our platform. In 2021, Humana implemented Cohere across 12 states, affecting 2.5 million covered lives. Nearly one year later, the results are in.

Here are some highlights from this highly successful implementation:

Pathways, Not Transactions:
PA processes typically emphasize singular transactions, often requiring a practice to submit multiple requests for treatments within the same care episode to different vendors using different channels. Cohere removes the hassle not only by encouraging the use of our digital prior authorization platform, but by having physicians submit for multiple services on a care pathway at once and then comparing what is prescribed to evidence-based guidelines. Treatments that match evidence-based standards are approved immediately and the user is informed that any requests that do not match will require further review. The bluntness of denial without specification is removed entirely and treatment can begin faster. 

Users Enjoy the Simplicity:
Response from practices has been extremely positive in the first year. The portal enjoys a high adoption rate of over 90% with the majority of users saying that it is simpler to work with than other solutions. In our surveys, we’ve received glowing reviews from physicians regarding the ease of use – a testament to our focus on an enjoyable user experience with as little friction involved as possible. Physicians and their staff are no longer burdened by arduous processes and benefit from a significant reduction in time spent on authorizations.

Patients Take Priority:
Above all else, patients have received a higher caliber of care with Cohere. Cohere’s instant determination for 88% of requests has driven a 70% reduction in care delays.. But it’s not just about speed; the treatments patients are receiving are tailored to them, guiding those who may not be the best candidates for surgery to alternative measures like physical therapy. The impact is especially visible in total hip and knee replacements, where complication rates have been reduced by 18%. One of our initial goals was to take advantage of the information pooled between provider and payer during the authorization process and this figure demonstrates that coordination being realized. The new level of efficiency coupled with a higher-level evaluation of the care journey will mean better results for many patients to come.

To read the full case study with more statistics and examples, download it here. Humana will be expanding its use of Cohere in 2022 across all national markets and business lines, and we’re excited for the insights ahead.