Cohere Health, the technology vendor selected by the Centers for Medicare & Medicaid Services (CMS) to manage Medicare’s new prior authorization pilot in Texas in partnership with Novitas, has informed the Texas Medical Association that its online preapproval process is proving to be an expedient prior authorization tool.
Texas is one of six states participating in CMS’ Wasteful and Inappropriate Service Reduction (WISeR) Model for original Medicare, which applies a technology-assisted preauthorization process to a list of 14 services “along with human clinical review, to ensure timely and appropriate Medicare payment for select items and services.”
TMA has been meeting with Cohere since November – when Cohere’s role was announced – to better understand how WISeR will be implemented in Texas and to help educate physicians on the program and its progress.
A Cohere spokesperson told Texas Medicine Today that most prior authorization submissions via Cohere’s online process are approved in real time. If a physician submits a prior authorization request for one the 14 WISeR-covered services to Novitas, Texas’ Medicare administrator, Novitas will forward the request to Cohere within one calendar day, or as soon as possible.
However, if a physician chooses to submit claims directly to Novitas – without first seeking prior authorization – the claim is subject to requests for additional documentation and the prepayment medical review process which can significantly delay Novitas’ decision to approve or deny payment.
Per CMS, WISeR administrators (including Cohere for Texas) typically issue a prior authorization determination within three calendar days of an initial or resubmitted physician request. TMA President Jayesh “Jay” Shah, MD, says the updates are an encouraging sign for physicians who have been hesitant to transition to the Cohere portal for WISeR approvals. He also reminds physicians that denials will not be automatically determined and issued via Cohere’s technology aided system.
A “nonaffirmation” (i.e., denial) of a prior authorization submission requires review “by a human clinician with relevant clinical expertise” before the determination is issued. If a prior authorization is “nonaffirmed” by Cohere, a physician can resubmit the request and request peer-to-peer clinical review to inform the new determination. Under the peer-to-peer review process in WISeR, the requesting physician “will be connected with a clinician(s) with specialty expertise on the condition under review.”
TMA President-Elect Bradford Holland, MD, utilizes a sleep apnea device in his otolaryngology practice that is on the WISeR list, prompting his practice to begin using Cohere’s program. He and other physicians are hopeful for solutions to a prior authorization process he describes as often posing an unnecessary hurdle to necessary patient care.
“We want to try and see those [hurdles] minimized,” he said. “If a physician is recommending [a treatment] as a medical necessity, there should not be tremendous hurdles to jump when the physician is giving the standard of care and has determined that's what the patient needs.”
At the same time, Drs. Holland and Shah encourage TMA physicians to report any problems they encounter with WISeR to the association’s Knowledge Center.
“We need to know any issues with the WISeR Model that we can address during our conference calls,” Dr. Shah said, emphasizing TMA’s ongoing dialogue with Cohere.
In addition, Cohere is making a Zoom training session available on Wednesday, March 25 at 10 am CT.
Learn more about WISeR via TMA’s resource page, including its education sheet detailing the process and the services impacted.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.