Reducing the barriers of prior authorization | Data Book podcast

Siva Namasivayam, the CEO of Cohere Health, spoke with Chief Healthcare Executive's "Data Book" podcast about using AI to improve prior authorization.

Siva Namasivayam says he’s passionate about solving some of the most difficult problems in healthcare.

Namasivayam is the CEO of Cohere Health, a healthcare technology company based in Boston. The company is working to remove some of the headaches in the process of prior authorization, which requires doctors, health systems and medical practices to get the approval of payers on certain treatments, drugs and procedures.

In the latest episode of the Data Book podcast, he says he wants to “try to solve it using all the greatest tools right now available in terms of data and technology.”

Doctors and hospitals have long lambasted the prior authorization process. They say it leads to delays in patients getting necessary treatments and can lead to worse outcomes, with some patients giving up on care. Hospitals and medical groups also say that the prior authorization process adds heavily to the burnout among physicians. For their part, payers say the prior authorization process helps control costs and curbs unnecessary procedures.

Cohere Health works with providers to try and help them avoid hassles in getting approval. Using artificial intelligence, the company’s technology reviews medical records to say if a treatment plan meets a payer’s requirements, or if the insurer is going to need additional information.

Most of the time, Cohere’s technology finds the procedures would be approved, but Namasivayam says the process allows providers to know earlier which treatments will require more documentation, potentially avoiding clashes with payers.

Cohere is doing millions of transactions annually. Namasivayam says his company is aiming to reduce tension between payers and providers, and leading to better care for patients.

The company says it’s reducing the time in getting decisions on authorization decisions.

Improving the prior authorization process is also a health equity issue, Namasivayam says. Healthcare providers with more modest resources and equipment have to spend more time in manpower on the process, adding to delays in patients getting approval for their treatments.

Namasivayam says he’d like more conversations between providers and payers on authorization centered on patient safety.

“That's not what is being done today, because many health plans are just saying yes or no,” he says. “But I think they need to go beyond that to come up with, what is the best treatment for the patient? Where can they get it, how they can get it and being able to communicate that, and here are the alternatives available.

“I think that the provider should be pushing their health plans also to do this, so that everyone is actually trying to work to the benefit of the patient,” he adds. “That should be the goal.”