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Analysis

Humana Partnership Streamlines Prior Authorizations Across 12 States

By Alexandra Wilson Pecci  
   October 22, 2020

Using the CohereNext platform's prior authorization capability grants authorizations across an entire episode of care, effectively pre-authorizing a patient's complete treatment regimen from start to finish.

Humana is partnering with the healthcare tech company Cohere Health to grant authorizations across an entire episode of care for musculoskeletal treatment across 12 states starting January 1, 2021.

The CohereNext platform's prior authorization capability grants authorizations across an entire episode of care, effectively pre-authorizing a patient's complete treatment regimen from start to finish.

Humana will use the platform to streamline prior authorizations in musculoskeletal treatment in Alabama, Georgia, Indiana, Kentucky, Michigan, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia.

It will initially serve approximately 2 million members and more than 3,500 physician practices. 

The platform includes:

  • Authorizations that begin with diagnoses and not billing codes
     
  • Facilitating and auto-approving evidence-based treatment plans
     
  • Delivering a peer review process with a true peer specialist or sub-specialist
     
  • Sharing quality performance relative to peers for specific care paths and patient cohorts
     
  • Providing tools, data and technology that optimizes value-based payment

“Through this strategic initiative and collaboration with Cohere Health, Humana is building on its commitment to reduce the complexity and friction of prior authorization for our physicians and members,” said William Shrank, MD, MSHS, Humana's chief medical officer. “Cohere's solution was co-designed with physicians and represents a major leap forward in improved physician experience and the adoption of evidence-based medicine.”

According to Humana, the partnership supports its "vision to reimagine and modernize processes for prior authorization by reducing approval times and improving delivery of care, all while preserving important benefits such as safety, predictability and cost containment."

The Humana-Cohere Health partnership is the latest of several payer efforts to remove the administrative burden and siloed nature of the authorization and reimbursement process.

For instance, Horizon Blue Cross Blue Shield of New Jersey and Atlantic Health System are seeing early success with a model in which the two New Jersey organizations share the financial accountability for the health, quality of outcomes, and total cost of care for a specified population of patients.

In addition, CommonSpirit Health, Blue Shield of California, and tech startup OODA Health have been working on a partnership that enables "a new type of revenue cycle arrangement" in which OODA pays the provider for the patient portion of the balance at the same time the payer sends its payment to the provider, according to Sophie Pinkard, co-founder and head of product at OODA Health.

Alexandra Wilson Pecci is an editor for HealthLeaders.


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