Transform Data and Care Management for Payers

Bringing together a member’s clinical, claims, social determinant, and other data helps you keep members healthy while improving your business processes. It’s essential to an enterprise data strategy that enables payers to:

• Meet regulatory requirements, such as CMS interoperability rules
• Improve care coordination and management across organizations and settings
• Enhance quality and streamline measurement
• Engage and optimize your provider network
• Improve operational efficiency
  

Earlier CMS rulemaking was designed to lay an interoperability foundation for payers, based on the HL7® FHIR® standard, for more coordinated care and the development of a mobile app ecosystem for members to manage their own health. CMS-0057-F builds on this foundation, expanding the role and scope of FHIR APIs and their use in streamlining prior authorization. It also recognizes the importance of payers as custodians of longitudinal health records.

Technical components of the rule – that is, support for the 4 specified APIs – take effect in January of 2027. InterSystems Payer Solutions offer you a path to compliance, whether you need help with one element, or the entire mandate. CMS has strongly encouraged the use of implementation guides and expertise developed by the HL7 Da Vinci project. InterSystems is a long-time member and active participant in the Da Vinci project and is ready to assist you in preparing your compliance plan now.

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The CMS Interoperability and Patient Access Rule is the starting point for payer interoperability. InterSystems Payer Services let you update or replace that foundation while moving forward to address new mandates.

Now that the No Surprises Act has gone into effect, payers need to make sure that they have a good, clean, accurate provider data. HealthShare Provider Directory allows payers to ingest, curate and manage their provider data, using rules and logic to make the best decisions about the most current and accurate information.

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Chronically ill patients with highly fragmented care cost almost double that of members whose care was well coordinated, and were more likely to have preventable hospitalizations. Under value-based care arrangements, care coordination is a team sport involving: providers, payers and members. All the players need a shared view of the data.

HealthShare’s Care Management Notifications, receiving real-time clinical feeds, can send out alerts on inpatient and emergency department admissions to the primary care provider and the payer. The alerts enable better care coordination for the patient, and automatic enrollment through HealthShare into care management programs. The clinical data also can populate Care Management/Utilization Management systems, assuring current and accurate information.

Learn More About Crossing the Payer Provider Chasm

Improvement happens continuously, not 90 days ago. Current clinical data gives you the information and perspective needed to make course corrections. Recognizing this, NCQA™ continues to expand ways clinical data can be used in support of HEDIS measurement:

• Real-time clinical data from  HealthShare can feed HEDIS and STARS quality measures, allowing for continuous monitoring and improvement
• Data sourced through HealthShare has met NCQA™ audit requirements
• InterSystems customers have achieved NCQA Validation status as participants in the Data Aggregator Validation program
• As a participant in the HL7 Da Vinci project, InterSystems has implemented the Data Exchange for Quality Measures use case using HL7 FHIR

Which manual payer/provider process cries out for automation? If you said prior authorization you’re not alone. The prior authorization process costs $23 to $31 billion per year in the US, according to a study published in Health Affairs. The health plan cost per manual prior authorization is $3.68, compared to $0.04 per electronic prior authorization, according to a 2017 Chilmark Research report.

It’s not just the bank account that suffers. Delays in the process affect provider morale and patient care. Combined, physicians and nurses spend about three and 13 hours a week, respectively, dealing with prior authorizations – time better spent with patients.

Reimagining this and other processes to make them more efficient requires access to clinical data, provided through InterSystems HealthShare. Examples, in addition to prior authorization and utilization management, include compliance with state or federal programs such as lead screening, and eliminating the HEDIS chart chase.

As a health plan, your greatest asset is your provider network. The more they provide cost effective quality care to members, the better it is for everyone. The key is transparency in data sharing: Making it possible for providers to see how they are performing against value based contracts, giving them insight into a longitudinal view of the care record, and helping them to succeed.