Geisinger Health Plan Partners on Utilization Management

July 18, 2022
Pennsylvania integrated health system is working with Cohere Health to improve the prior authorization process, drive better care experiences and outcomes

Pennsylvania-based Geisinger Health Plan (GHP) is partnering with a company called Cohere Health on prior authorization and utilization management.

GHP will use Cohere’s AI-driven and machine learning technology to streamline 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. The company said that 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.

Cohere said its utilization management 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.

“Working with Cohere Health is a transformational step in Geisinger’s long history of clinical innovation, both in Pennsylvania and nationwide,” said John Bulger, M.D., chief medical officer for Geisinger Health Plan, in a statement.  “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.”

Geisinger Health Plan 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.

 Cohere says its platform ensures that prior authorization requests are evidence-based before submission. By offering clinical guidance at the point of authorization, the platform drives 15 percent incremental medical savings, on average, while simultaneously reducing denial rates by 63 percent, the company claims. The platform is designed to reduce provider friction throughout the prior authorization process, an imperative for GHP.

Cohere also said its platform delivers digital submission rates of up to 95 percent, with the majority of cases determined in real time.

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