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Humana Expands Prior Auth. Partnership With Cohere Health

Analysis  |  By Marie DeFreitas  
   April 25, 2024

The platform is giving physicians faith in quick prior authorization turnaround.

Payer giant Humana has expanded its partnership with Cohere Health’s prior authorization platform for diagnostic imaging and sleep services.

Cohere Health is a startup clinical intelligence company that aims to reduce administrative expenses while improving patient outcomes through intelligent prior authorization. The company’s platform uses AI to accelerate the prior authorization process by using predictive technology coupled with clinical intelligence. The platform is able to give providers suggestions before submitting prior authorization requests, aiming to lower payer denial rates.

 The two companies began a partnership in January 2021 with a pilot program in 12 states to improve the prior authorization process for musculoskeletal (MSK) services. After the program proved successful in reducing prior authorization approval turnaround times, as well as increasing provider satisfaction, it was expanded to all 50 states in 2022. By January 2023 Cohere’s platform was established nationwide with the addition of cardiovascular and surgical services.

The expanded partnership, announced this week, added diagnostic imaging and sleep solutions to Humana’s member services.

"We're pleased Humana will be utilizing our diagnostic imaging and sleep solutions, further strengthening our strategic and ongoing partnership," said Siva Namasivayam, Chief Executive Officer of Cohere Health. "Our solutions are rooted in the latest evidenced-based guidelines from leading medical societies and use advanced technology to align patient services within care pathways through upstream moments of influence, ultimately enabling faster diagnoses."

Payers & Prior Authorization

Payers should take note on the outcomes of this partnership. Prior authorization is one of the biggest problems providers face, and in the past has often led to contemptuous relations with payers, even lawsuits.

A survey released by the American Medical Association earlier this year found that 94% of physicians say prior authorization leads to delays in patient care. It also found that one in three physicians, about 33%, say prior authorization has led to serious adverse events with their patients.

The CMS have proposed changes in prior authorization practices, which the healthcare industry has seen as a step in the right direction. CMS has urged some payers to transition to electronic authorizations by 2026, as well as aim for shorter turnaround times.

Using AI for prior authorization right now can be a slippery slope. We saw Humana abuse the veil of AI to dish out denials, which resulted in a class-action lawsuit. This time around it seems their use of AI in prior authorization has achieved much better results, and importantly, satisfied, less-stressed providers who are able to provide better clinical outcomes for their patients.

"Diagnostic imaging is often the start of a patient's journey, and we are confident our collaboration will further elevate our members' overall healthcare journey and streamline administrative tasks for our providers," Humana Senior Vice President of Clinical Operations Lisa Stephens said in the release.

Marie DeFreitas is the finance editor for HealthLeaders.


The partnership has seen promising results thus far.

Humana has previously been hit with lawsuits over prior authorization practices.

Physicians cite prior authorization as one of their biggest hurdles to providing care.

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