Cohere & AAOS team up to address the CMS prior authorization final rule

Last month I had the privilege of co-authoring a white paper with our partners at the American Academy of Orthopaedic Surgeons (AAOS) , exploring how health plans can prepare for compliance with the recently finalized CMS Interoperability and Prior Authorization Final Rule.

As an AAOS fellow, practicing orthopedic surgeon for more than 20 years, and clinical leader at Cohere Health , I have experienced first-hand the slow and cumbersome nature of the traditional prior authorization process–and I know there’s a better way.

The CMS final rule is an opportunity for health plans to actually transform their prior authorization process to drive better collaboration with physicians and ultimately improve patient care.

Cohere teamed up with AAOS on this timely paper to help health plans understand not only the impending federal regulations and important deadlines, but also how they should use regulatory compliance as a catalyst for greater change, care collaboration, and transparency.

The Interoperability and Prior Authorization Final Rule represents a critical step toward remedying the significant challenges and delays faced by patients, providers, and health plans when navigating prior authorization.

In particular, the rule contains four key provisions around improving the prior authorization process, making it more efficient and less of an administrative burden, while also enhancing the accessibility of health information for patients and their care teams.

• ?? Interoperability: Implementing the required APIs will improve access to health data, giving patients and their care teams more insight into the PA process.
• ? Turnaround time:? Health plans must issue decisions within 72 hours for expedited (urgent) requests and seven calendar days for standard (non-urgent) requests, helping patients get their care sooner.
• ?? Transparency: Come 2026, health plans will need to provide specific reasons for denials, increasing transparency of authorization decision-making and reducing provider friction.
• ??? Accountability: Health plans must publicly disclose certain prior authorization metrics annually, which will help bolster relationships between plans and their provider networks.

With implementation deadlines quickly approaching (some as early as 2026), forward-thinking health plans should be assessing and implementing solutions for complying with the new requirements. Certain solutions, like intelligent prior authorization, can help plans both comply with the requirements and use compliance as a catalyst for utilization management innovation.

Some ways intelligent prior authorization is already helping our health plan partners:?

• 50-80% auto-approval rate for appropriate care (varies by specialty)
• Providers report 5 days faster access to care for their patients
• 91% provider satisfaction?

In the white paper, we break down the main components of the rule and dive into how intelligent prior authorization and artificial intelligence can serve as strategic solutions for regulatory compliance.

Impacted plans should view regulatory compliance, and the resulting prior authorization transformation, as an opportunity: to improve care quality and access; to increase interoperability between stakeholders; and to enable more successful value-based care across the healthcare space.

If you’re ready to learn more, I encourage you to download our white paper, How keeping up with CMS regulatory changes will drive better patient outcomes.?

Come see how intelligent prior authorization is helping Cohere’s health plan partners comply with regulations while improving provider experience and patients’ outcomes.