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Debunking Tradeoffs between Compliance and Better Care

WEDI Spotlight Session

Leveraging CMS‑0057 to scale ePA and advance value‑based care

Learn how payers can move beyond “check‑the‑box” compliance to operational wins—embedding ePA into provider workflows, activating FHIR‑based exchanges, and using longitudinal health records to improve quality and Stars.

CMS‑0057 sets the floor for transparency, timeliness, and electronic prior authorization. In this WEDI spotlight, InterSystems Steven Berkow shows how payers can convert mandated APIs into measurable impact—embedding CRD/DTR/PAS into provider workflows, orchestrating back‑office automation, and leveraging longitudinal health records to lift quality and Stars. The session also previews practical DTR simplification and a panel on applying AI to transform prior authorization.

Key Takeaways

  • Beyond compliance → impact
    How to translate CMS‑0057 mandates into measurable outcomes (quality/Stars, member experience, admin cost).
  • In‑EHR workflows (CRD/DTR/PAS)
    What it takes for clinicians to see guidance and determinations inside the EHR—no swivel‑chair.
  • Real adoption barriers (from WEDI)
    Provider workflow change aversion and variability in applying burden‑reduction IGs—and how leading plans are addressing both.
  • The plan “gameboard” architecture
    Put mandated APIs at the center, add multi‑point provider connections (native/EHR/hubs) on the left, and automate/back‑office orchestration (rules, UM systems, API management) on the right.
  • Pragmatic rollout strategy
    Prioritize 80/20 wins, set a realistic glide path, and use change‑management tactics with trusted influencers.
  • Longitudinal Health Record (LHR/UCR)
    Why ingest, harmonize and make usable clinical data (and avoid re‑asking providers) to power care gaps, analytics and operations.
  • Payer‑to‑payer exchange—operational realities
    Expect member opt‑in, prior/concurrent payer identification, and update‑cadence planning.
  • AI depends on clean data
    Data quality and availability drive AI/analytics value; invest in pipelines and standards first.

Speakers

  • Steven Berkow, Senior Advisor, Value‑based Care, InterSystems
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