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The concept of using artificial intelligence to streamline the prior authorization process sounds like a great idea. What will that look like in an actual medical practice? And how will patients respond? Brian Covino, MD, chief medical officer at Cohere Health, spoke with Medical Economics about a coming shift toward touchless prior authorization Cohere Health and other vendors are building ahead of new federal deadlines.
The CMS Deadline Behind This Touchless Prior Authorization Cohere Health Vision
The U.S. Centers for Medicare & Medicaid Services has set Jan. 1, 2027, as the date to comply with CMS-0057-F, the CMS Interoperability and Prior Authorization Final Rule, which requires health plans to run four standardized electronic systems, including one built specifically for prior authorization requests. Cohere Health joined the new CMS Electronic Prior Authorization Acceleration Initiative, a coalition of health plans, providers and technology vendors working to meet that deadline.
Which Specialties Stand to Benefit Most
“For health plans, a lot of the bulk of utilization management and prior authorization is in areas such as musculoskeletal medicine, myself being an orthopedic surgeon, cardiology, imaging and oncology,” Covino said. “We’ve partnered with some specialty medical societies, such as the American Academy of Orthopaedic Surgeons and the American College of Cardiology, to use the appropriate-use guidelines those societies have created and embed them into our decision-making.”
How This Touchless Prior Authorization Cohere Health Approach Uses Specialty Guidelines
“We can codify their policies and digitize them, so that when we’re extracting information, if a request meets those guidelines, it can get approved,” Covino said. “I think AI will be very helpful in those areas because they’re high-volume. Imaging, for example, is a very high-volume area for prior authorization.” He added that primary care physicians submit a significant portion of prior authorization requests despite having limited time, and that standardization would help both them and their staff.
A Direct Message to Primary Care Physicians
“My message to primary care physicians is: We appreciate what you do. Help is here, and help is on the way, to try to make your lives easier for the tremendous number of patients you care for on a daily basis,” Covino said.
What Touchless Authorization Would Actually Look Like in Practice
“I think the future state of this is what we’d call touchless authorization,” Covino said. “Most primary care physicians’ offices now have electronic health records, so ideally, while a patient is still sitting with the physician and the physician says, ‘We ought to get an ultrasound or a CT scan of this,’ they could enter that order into their system, and that would immediately start the prior authorization process through the EHR.”
The Interoperability Piece This Vision Depends On
“We could connect to that, and once we’re notified, we could start pulling the information out of the EHR. Right now, physicians and their staff have to push the information to us,” Covino explained. “If we could be interoperable and pull it from the EHR or from the health plan’s claims on that patient, to make sure they haven’t already had that done somewhere else, we could get the approval while the patient is still sitting in the office.”
How Covino Frames the Patient Experience Gap
“Think about a patient who drives an hour or two to see a doctor and is told, ‘You need a test done, come back in two weeks once I find out if it’s approved.’ Compare that to, ‘It just got approved, let’s send you next door and have this test done right now.’ I think that’s the future of it, where we can make this touchless, and continue to increase efficiency and reduce delays.”
Addressing Patient Skepticism About AI in Prior Authorization
Surveys, including one from the American Medical Association, have found patient skepticism about AI in healthcare and administrative decisions. “We don’t talk directly to patients, but we talk to the practices treating them, and it’s been pretty uniformly well received,” Covino said. “I think the reason is that patients are getting approvals very quickly for appropriate care, so some of that initial skepticism, which is understandable, creates less concern once they see their doctor scheduling their procedure or test faster.”
Why Physician Involvement Matters for This Touchless Prior Authorization Cohere Health Vision
“Some of that skepticism is somewhat healthy, though, and it goes back to educating physicians, clinicians and patients about the appropriate use of this technology,” Covino said, noting that physicians, not just technologists, have been involved in building these tools from the start.
A Response to EHR Frustration
Physicians have said EHRs were imposed on them by insurers without much input. “I agree, and I’ll tell you that from the very beginning at Cohere, even when this was a concept developed within a health plan before it became a company, there was physician involvement from the start,” Covino said. “Those of us who had been in practice knew the problems with the process; we could tell you very clearly what the issues were, so we knew where to go and what to try to solve.”
Why Covino Says Prior Authorization Isn’t Going Away
“It’s an onerous process, and it’s probably not going away, because unfortunately we still have a small percentage of care delivered in this country that’s wasteful, inappropriate and part of why health care is so expensive,” Covino said. “Health plans really want to change it, too, and CMS and the Center for Medicare and Medicaid Innovation really want to solve this for Medicare and Medicaid beneficiaries as well.”
A Broader Framing of the Effort
“There are good people, both in private industry and in government, working to solve this problem,” Covino said. “It’s not easy, and it takes time, but there are a lot of good people trying to make this better, because we all want to make sure our health care industry stays the best, and hopefully becomes less expensive than it is currently.”
What This Touchless Prior Authorization Cohere Health Vision Means Going Forward
With the Jan. 1, 2027 CMS compliance deadline approaching, health plans, providers, and technology vendors participating in the Electronic Prior Authorization Acceleration Initiative will need to demonstrate whether the touchless authorization model Covino describes can move from concept to reliable, real-time practice at scale. Given Covino’s emphasis on specialty-specific appropriate-use guidelines from organizations like the American Academy of Orthopaedic Surgeons and the American College of Cardiology, high-volume specialties such as imaging, cardiology, and musculoskeletal medicine may see the earliest and most measurable improvements from AI-assisted prior authorization ahead of practices in lower-volume specialties.
What to Watch Going Forward
As the industry approaches the January 2027 deadline, practices and patients will likely watch whether the same-visit, EHR-triggered approval process Covino envisions becomes a widespread reality or remains aspirational for now, particularly given the interoperability infrastructure such a system depends on. Given the persistent patient and physician skepticism documented in AMA’s survey, the success of this touchless prior authorization Cohere Health vision may ultimately hinge on whether health plans and vendors can demonstrate, at scale, the kind of physician-led development and faster approval outcomes Covino describes from his own organization’s early experience.
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