The challenges of a one-size-fits-all approach
Health plans often treat all providers the same in the prior authorization (PA) process, much like giving every gym member the same workout plan—whether they’re a beginner just starting their fitness journey or an elite athlete pushing for peak performance. While this might seem efficient, it overlooks the diverse needs of providers, which can lead to significant challenges for providers and health plans.
For high-performing providers—those who consistently submit clinically appropriate requests, attach the necessary documentation, and maintain high approval rates—the standard PA process feels like an endless cycle of basic drills despite their advanced skills. This leads to unnecessary frustration and inefficiency that detracts from their ability to focus on delivering high-quality care.
On the other hand, health plans struggle to drive behavior change among providers who don’t meet PA standards. Some providers may require additional education and support to navigate the PA process effectively, while others may benefit from more structured guidance to ensure complete submissions and clinically appropriate utilization. Like a generic fitness plan that doesn’t address an individual’s needs, traditional PA processes fail to offer the tailored support necessary to help these providers get back on track. Addressing issues like overutilization, incomplete submissions, and clinical attachment deficiencies is nearly impossible without targeted coaching or guidance.
Many health plans have turned to gold card programs or other exemptions to reduce provider abrasion, offering high performers relief from the standard PA process. While these initiatives seem like a quick fix, they bring their own set of challenges:
📈 Increased utilization and medical expenses
🎯 Lack of precision and flexibility
❌ Lack of transparency for providers
📊 Inability to monitor real-time trends and ongoing performance
⏳ Long delays in updating programs
A smarter plan for PA: Cohere Align™
Just as a personal trainer tailors a fitness plan to each individual’s needs, an ideal PA solution should be customized to each provider’s performance. A one-size-fits-all approach simply doesn’t work—just as a generic workout plan can’t help elite athletes reach their peak potential, a standard PA process fails to optimize provider outcomes. With Cohere Align, health plans can create a dynamic and personalized PA experience that adjusts the level of effort and guidance each provider receives based on their performance and needs.
The key to Cohere Align’s success lies in three essential areas:
- Identify: We analyze provider behaviors to create meaningful, performance-based cohorts. Using provider performance data, we group them in ways that allow targeted, impactful interventions.
- Engage: We deploy tailored strategies for each cohort. For high performers, this means reducing friction and offering relief, while for low performers, we provide educational nudges and coaching to promote desired behaviors and improve clinical outcomes.
- Monitor: Just like a personal trainer adjusts a fitness plan as progress is made, Cohere Align continuously tracks and refines performance in real time, ensuring that providers stay on track for continuous improvement and consistently deliver effective care.
What Cohere Align can help you achieve: A win-win for health plans and providers
Cohere Align shifts from a traditional, static PA process to a personalized approach that aligns with the unique performance levels of each provider. This tailored method benefits both health plans and providers in significant ways:
- Reduce provider abrasion: By eliminating unnecessary administrative burdens for high performers, Cohere Align reduces submission time by 55%* and boosts provider satisfaction to 98%.+
- Lower operational cost: By increasing auto-approval rates for trusted providers, health plans can save $30–$60 in operational costs per manual review. This translated to an estimated $500K in annual savings for one plan.
- Increase transparency and provider engagement: Cohere Align fosters greater transparency by offering targeted educational guidance to providers with incomplete or missing information. This leads to a 92% improvement in clinical attachment rates+ within 30 days, encouraging providers to engage more deeply with the PA process.
- Maintain control and security: With advanced monitoring tools, health plans can quickly detect performance changes and adjust workflows in real-time, reducing medex risk by two-thirds+ and ensuring long-term control and sustainability.
Unlike traditional PA programs or gold card initiatives that provide temporary fixes, Cohere Align offers a comprehensive, real-time, and transparent solution. By delivering tailored workflows and consistently adjusting to provider performance, this approach enables health plans to effectively manage prior authorization, enhance provider outcomes, and minimize administrative friction.
The future of provider PA experience
Cohere Align isn’t just a solution—it’s a transformation in how health plans manage prior authorization. It identifies and helps address the unique needs of each provider, moving beyond the limitations of traditional PA processes. This approach reduces administrative friction for high performers and offers the tools necessary to guide low performers toward better behaviors, ultimately driving improved clinical outcomes.
Cohere Align empowers health plans to retire temporary fixes and introduces a sustainable, data-driven system that continuously adapts to provider performance. Ready to experience a smarter, more efficient way to handle PA? Learn more about Cohere Align here.
* The 55% reduction in submission time was calculated by comparing the time to submit without CAQs/attachments (via Align) to the time with.
+ Based on 2024 Cohere pilot program data
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About the Author: Cohere Health
