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Improving the Speed and Transparency of Authorizations through FHIR API–Enabled Data Sharing

KLAS Research: Points of Light Case Study

Executive Summary

KLAS points of light badge

Prior authorizations for referrals and clinical procedures are widely acknowledged as a significant pain point for all involved parties—payers, providers, and patients. Using implementation guides from HL7’s Da Vinci Project, the collaborators in this case study created bidirectional data exchange through a FHIR API that enables an automated, in-workflow authorization process. The pilot use cases have been successful, achieving improved efficiency, reduced costs, and—most critically— more timely care and improved patient outcomes.

Points of Light—Outcomes Achieved through Collaboration
  • Improved efficiency through automated workflows that facilitate timely authorizations for therapeutic Botox treatments
  • Improved processes and governance for both parties
  • Cost savings for both parties through significant reduction in manual processes
  • Improved patient outcomes via more timely access to care
  • Three-year CMS exemption that allows electronic data to be transferred as FHIR bundles rather than the standard, HIPAA-required X12, 275, and 278 transactions

Download the KLAS Research Points of Light Case Study to learn more about the collaboration between UC Davis Health, a Payer Organization, and InterSystems, Including:

  • Points of Friction—Challenges to Be Solved
    • High administrative costs associated with labor-intensive authorization processes
    • Siloed workflows and lack of transparency between payers and providers create churn and delay care
  • Action Plan—How the Collaborators Worked Together to Reduce Friction
    • Partnered on a pilot to automate authorization requests and approvals for therapeutic Botox treatments
    • Identified mutual business goals and success metrics
    • Established bidirectional, in-workflow data sharing between the payer and provider organizations
    • Obtained three-year CMS waiver exempting the collaborators from HIPAA requirements for electronic transactions
  • Lessons Learned—What Best Practices Can Other Organizations Replicate?
    • Develop a collaborative statement of work that includes all stakeholders (payer, provider, and IT vendor)
    • Start with a pilot and be clear about the commitment and availability of financial and human resources
    • Benefits can be gained without adding to already onerous administrative burdens
  • What’s Next?—Vision for the Future
    • Identify additional use cases and payer/provider partners
    • Prove to CMS that the project has reduced the administrative burden
    • Build a consent model

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