What You Should Know:
– Today Geisinger Health Plan (GHP) and Cohere Health, a provider of utilization management (UM) technology, announced they are joining forces to streamline the prior authorization process for providers.
– Cohere’s collaborative UM platform will help GHP support value-based care delivery, reduce administrative costs, and lead the nation in aligning quality improvement initiatives across all its lines of business, including Commercial, Exchange, Medicare Advantage, and the newly expanded Medicaid.
Evidence-Based Prior Authorization
GHP provides coverage to more than half a million members throughout Pennsylvania and boasts a network of more than 30,000 primary and specialty care physicians. GHP will utilize Cohere’s AI-driven and machine learning technology to accelerate patient access to high-quality care while streamlining prior authorization. Cohere’s digital platform creates episode-specific care paths based on the member’s utilization history and individual care needs, in addition to historic results for a specific patient population. Fully transparent, evidence-based suggestions prompt providers to select high-value care options before requests are submitted, reducing peer-to-peer clinical reviews and denials. Initial clinical improvement programs will focus on increasing patient access to conservative and home-based treatments.
The Cohere platform increases health plan savings beyond traditional UM, as it ensures that prior authorization requests are evidence-based before submission. By offering clinical guidance at the point of authorization, the platform drives 15% incremental medical savings, on average, while simultaneously reducing denial rates by 63%. The platform is designed to reduce provider friction throughout the prior authorization process, an imperative for GHP.
Cohere’s platform delivers digital submission rates of up to 95%. The majority of cases are determined in real-time, returning immediate approvals that expedite patients’ access to care by 70%. Cohere has also seen surgical complication rates decrease by 18%. By supporting ordering providers with data, as well as transparent, clinically driven “nudges,” the Cohere platform will build trust with network providers and enable GHP to reduce care variation and incentivize high-value care.
“Working with Cohere Health is a transformational step in Geisinger’s long history of clinical innovation, both in Pennsylvania and nationwide,” said John Bulger, MD, chief medical officer for Geisinger Health Plan. “We’re excited not only to significantly improve the prior authorization process, but also to drive better care experiences and outcomes for our providers and members. Cohere’s collaborative platform enables us to further differentiate our value-based care offerings, as our network providers can use the platform’s evidence-based, proactive care suggestions to make better health easier and ensure our patients receive optimal care specific to their medical history and condition.”