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RESPONSIBLE AI AND THE PRIOR AUTHORIZATION TRENDS MAKING WAVES IN 2023

ONGOING MEDIA CRITICISM OF PRIOR AUTHORIZATION CATALYZES STATE AND FEDERAL
REGULATORY ACTION

The past several months have seen non-stop media coverage and criticism of the
prior authorization process and of utilization management in general.

Some of the media highlights I’ve noticed include:

 * 2022 The American Medical Association (AMA) physician survey: 94% of
   physicians report care delays associated with prior authorization
 * Bills in 30 states show momentum to fix prior authorization
 * ProPublica revealed that over a period of two months in 2022, Cigna doctors
   denied more than 300,000 claims as part of a review process that used
   artificial intelligence, with Cigna doctors spending an average of 1.2
   seconds on each case.

Most recently, I’ve been intrigued by a larger discussion in tech about
“responsible AI.” With McKinsey estimating that generative AI can help
healthcare realize $1 trillion in improvement potential, it’s no wonder
healthtech companies are focused on adopting new uses for the advanced
technology. The use of AI in process automation is fairly widespread, but new
generative capabilities have got everyone thinking about using AI to supplement
tasks previously thought to require a “human touch.” When implementing AI in our
solutions, we utilize a core set of principles: accountability, transparency,
privacy and security, and inclusiveness and fairness, to make sure that AI is
not replacing the work done by humans, but instead changing the way humans work
to make the prior authorization process more efficient, and for the process to
actually improve care quality and access.

The AMA is a leader in advocating for policies to improve the burden of prior
authorization, but with the buzz around generative AI, they issued a statement
calling for more oversight of AI in prior authorization, urging plans to
consider ethically automating prior authorization and reducing the number of
services requiring prior authorization.

Luckily, state and federal governing bodies understand the urgency to regulate
prior authorization reform. In the past year, they have passed legislation and
introduced new regulations in response to these popular criticisms, but it can
be a little overwhelming for health plans trying to stay ahead of the curve.

Here’s a refresh of the regulatory highlights of 2023 . . . to date!

UTILIZATION MANAGEMENT REQUIREMENTS OF CMS’S MA AND PART D FINAL RULE EMPHASIZE
TIMELY ACCESS TO CARE

Reflecting on these impacts and responses, we are seeing three changes catalyzed
by the pandemic:

Health plans must act immediately to implement the provisions included in the
CMS Medicare Advantage and Part D Final Rule by January 2024. Any new
initiatives on this front will likely help plans’ larger regulatory compliance
strategies for upcoming CMS rules and state legislation. Intelligent prior
authorization solutions enable regulatory compliance with utilization management
provisions and drive:

 * Improved patient outcomes
 * Reduced delays in care
 * Promotion of health equity among Medicare beneficiaries
 * Increased transparency for physicians and health plans

This article by Alina Czekai, Vice President of Strategic Partnerships, explores
how intelligent prior authorization uses AI to deliver added value while
enabling plans to comply with the rule’s UM provisions. One example to look out
for is how Cohere is using AI to reduce low-value utilization by up to 15% using
pre-submission influence technology, like nudges.

CMS IS LEVERAGING PRIOR AUTHORIZATION TRANSACTIONS TO IMPROVE INTEROPERABILITY
AND TRANSPARENCY

Despite the regulatory progress made in improving interoperability challenges
in  healthcare, some challenges persist. CMS’s prior authorization and
interoperability proposed rule targets the following remaining areas:

 * Lack of a standardized application programming interface (API)
 * Fragmented health information exchanges (HIEs)
 * Minimal incentive for data exchange between healthcare stakeholders

Two key provisions in the rule relate specifically to improving
interoperability, transparency, and data exchange between providers, health
plans, and patients.

 * Health plans must build and maintain a Fast Healthcare Interoperability
   Resources (FHIR) API (PARDD API) that automates the process for providers to
   determine prior authorization requirements, documentation, and decision
   guidelines. 
 * Health plans must also include a specific reason when denying a prior
   authorization request

Engineering Operations Manager Jason Amaral breaks down how intelligent prior
authorization solutions help health plans solve interoperability and
transparency challenges in this article. In it, you’ll also find how Cohere uses
clinical intelligence to package the most relevant information from
provider-submitted evidence for reviewers to accelerate manual review.

GREEN LIGHTING IS A DATA-DRIVEN ALTERNATIVE TO GOLD CARDING THAT REDUCES THE
BURDEN AND ENHANCES CARE QUALITY

Green lighting leverages real-time data-driven intelligence with industry and
peer benchmarking and evidence-based guidelines to isolate providers with
high-volume and outlier performance (percent approval and denial) for specific
service requests.

Green lighting uses ongoing and real-time provider evaluations instead of the
manual “moment in time” annual or semi-annual performance reviews commonly used.
Green lighting expedites the process, but does not exempt providers from
submitting clinical data. Therefore, green lighting criteria can be adjusted if
the utilization is inappropriately increasing.

Read more in this article by Tracy Zheng, PhD, Vice President of Clinical
Programs and Quality Analytics. You’ll learn how Cohere is using AI-driven
analytics in our green lighting program.

Download our white paper, Four Ways the CMS Prior Authorization and
Interoperability Rule Will Drive Better Patient Outcomes, to dive into how
intelligent prior authorization can help plans comply with federal regulations
while improving utilization and patient outcomes.

AVAILABLE FOR DOWNLOAD

White paper: Four Ways the CMS Prior Authorization and Interoperability Rule
Will Drive Better Patient Outcomes


Lead Subsource


Published On: August 3rd, 2023Categories: Blog

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ABOUT THE AUTHOR: BRIAN COVINO, M.D., FACC

Dr. Brian Covino oversees more than 50 physicians as Cohere Health’s Chief
Medical Officer. After practicing orthopedic surgery for more than 25 years, Dr.
Covino joined Cohere in 2020 after having served as a consultant since 2018.
During his years as a practicing surgeon, Dr. Covino was a partner at Knoxville
Orthopaedic Clinic/OrthoTennessee specializing in joint replacement surgery. He
holds a bachelor’s from Harvard University as well as an M.D. from Georgetown
University School of Medicine. Dr. Covino received his surgical training at the
University of Virginia Graduate School of Medical Education and completed a
fellowship at The Cleveland Clinic Foundation.
239 Causeway Street, Suite 200
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(833) 283-0033


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