How prior authorization promotes patient safety

It’s nice to have a doctor as a friend. Friends always reach out to me about a treatment plan and ask what I think about a certain medical procedure. When a doctor is a text or call away for a second opinion, it’s easier to feel confident about your care. 

But what if you don’t have a doctor friend? That’s when prior authorization can help. 

You don’t have to look hard to find complaints about prior authorization, and with good reason. However, the less discussed flipside of prior authorizations is how they can work as a second opinion for a patient. 

Here are two examples of how intelligent prior authorization can prevent risky events for patients:

1. Muskuloskeletal prior authorization example

Request: Kyphoplasty for treatment of an osteoporotic vertebral compression fracture

Result: The advanced imaging report showed retropulsion and canal compromise from the compression fracture at the level to be treated. This occurs when the vertebral bone has been pushed into the spinal canal. This is a patient safety issue because kyphoplasty with patients who have retropulsion on imaging can have catastrophic outcomes with cement in the spinal cord. This request was denied due to the imaging findings, and alternative, less risky treatments can be initiated. 

Request: Lumbar spine fusion for degenerative arthritis and stenosis. 

Result: Advanced imaging and attempted conservative care meets the guidelines for approval. However, the patient was an everyday smoker, and an individual must be nicotine-free for six weeks before the anticipated surgery date. There was no documentation of smoking cessation or a negative cotinine test. According to evidence-based guidelines, an active smoker has a higher risk of complications. This case went on to a peer to peer and the surgeon acknowledged that the patient is a smoker and is planning to refer to a smoking cessation program. The patient will continue on medications (Neurontin) and their home exercise program that was started two months ago.

2. Cardiovascular prior authorization example

Request: Intervention for patient with Intermittent claudication (IC), who did not fail conservative therapy. 

Result: Patients with IC are best treated by conservative treatment, including an exercise program, medications, or smoking cessation. Only if they still have persistent exercise related cramping in the buttock or calf, is the risk of intervention warranted. 

During the peer to peer (P2P) review, it was clear that the patient’s symptoms were documented to be claudication,  so intervention was withdrawn as it would not have benefited the patient and might have caused harm. A structured exercise program has been shown to improve  walking performance, functional status, and quality of life, according to the 2024 ACC/AHA Guidelines on Management of Patients with Lower Extremity Arterial Disease.

There’s prior authorization, and then there’s intelligent prior authorization. Learn more about how intelligent authorization promotes getting patients to the right care at the right time with: 

Innovations like green lighting

Green lighting evaluates ongoing and real-time provider prior authorization data against benchmarks, quality metrics, and evidence-based guidelines to empower high-value providers with fast approvals and minimal data submission.

Accreditation from NCQA

Cohere was the first intelligent prior authorization platform to earn Utilization Management Accreditation from the National Committee for Quality Assurance (NCQA). This accreditation validates compliance with the industry’s highest care quality standards and patient safety.