Summary
Download this research report to read the latest utilization trends from over one hundred health plans across lines of business and segments. Health plans can use the data from this study to maintain or even increase their medical cost savings, while actually reducing provider abrasion, without sacrificing care quality, by modifying their mix of medical services managed with prior authorization.
Some of the key trends from the data include:
- Health plans manage, on average, about 2,500 codes, with Blue Cross Blue Shield plans managing the fewest codes.
- Approximately 11% of utilization and 22% of spend is managed across lines of business, with commercial plans managing 9.2% of utilization and 22.5% of spend, Medicare plans managing 9.2% of utilization and 21.8% of spend, and Medicaid plans managing 16.3% of utilization and 20.0% of spend.
- Specialties with the most procedure codes managed include Surgery, DME, and MSK, with MSK having the highest utilization, and Pediatrics, Nephrology, and Endocrinology have the fewest codes, with Pediatrics and Dental having the lowest utilization.
- High utilization does not always correlate with high spend (or an area of high impact). While E/M services have a high utilization, requiring prior authorization in these areas would severely impact physician burden with little financial reward, whereas introducing prior authorization for high-cost surgeries could be more impactful, even if utilization is relatively low.
About Cohere Health
Cohere is a clinical intelligence company that provides intelligent prior authorization as a springboard to better quality outcomes by aligning physicians and health plans on evidence-based care paths for the patient’s entire care journey. Cohere’s intelligent prior authorization solutions reduce administrative expenses while improving patient outcomes. The company is a winner of the TripleTree iAward and has been named to both Fierce Healthcare’s Fierce 15 and CB Insights’ Digital Health 150 lists. Cohere’s investors include Flare Capital Partners, Define Ventures, Deerfield, Polaris Partners, and Longitude Capital.
