Commercial insurance giant Humana will be moving to a single vendor for musculoskeletal and therapy prior authorizations beginning Jan. 1, 2022, a decision that the insurer says is based in part on the success of the system in 12 states that were assigned to Cohere at the beginning of 2021.
According to an information sheet from Cohere, the prior authorization system will be used for most Humana commercial and Medicare members, where the company will be Humana's vendor for prior approval of CPT codes associated with musculoskeletal care and therapy. Services covered by the system include physical therapy, occupational therapy, speech therapy, orthopedic surgeries, and pain management services.
In a press release on the change, Cohere points to its experience with 12 states that began using the system in 2021. (The remaining 38 states have been using Orthonet for prior authorization services.) During that time, according to the company, Cohere reduced the need for manual review through the use of a digital automatic authorization process with a median approval time of "0 minutes." The reduced waits allowed providers to schedule patients for services immediately 89% of the time.
While the system doesn't officially launch nationwide until Jan. 1, 2022, Cohere and Humana are urging providers to register for Cohere, after which they can begin to submit actual authorizations to try out the system. According to Cohere, those pre-January authorizations will be considered valid and do not need to be submitted to other vendors.
APTA recently became aware of this transition and is working to gather more information from Humana and Cohere, engaging with providers in the states that were part of the 12-state implementation, and working to establish a system for addressing any issues associated with this transition. In the meantime, PTs should take advantage of the opportunity to learn about the Cohere platform, says Alice Bell, PT, DPT, APTA senior payment specialist.
"Providers should start familiarizing themselves with the system as soon as possible," Bell said. "We're continuing to gather more information on this transition but encourage providers to prepare now for the change." APTA will share more information on the Cohere system as it becomes available.