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Helping Public and Private Payers Make an Impact

Put Actionable Member-360 Information at the Center of Your Enterprise Data Management Strategy

doctors and nurses discussing information on a laptop

Engage Members, Improve Outcomes and Transform Care

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
Jeff Rivkin, Research Director of Payer IT Strategies, IDC Health Insights, Eight Drivers for Payer Interoperability Implementation, Now!

InterSystems is Helping Its Payer Customers Meet U.S. Regulatory Requirements

The Prior Authorization Mandate: Driving Interoperability, Improving Care Coordination, Reducing Burden and Empowering Members (CMS 0057-R)

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 to empower members to manage their own health. The proposed CMS 0057 rule builds on this foundation, expanding the role and scope of FHIR APIs and their use in streamlining prior authorization and other business processes. It also explicitly recognizes the importance of longitudinal health records to patients, providers, and payers for driving better outcomes.

Federal Register/Vol. 87, No. 238/Tuesday, December 13, 2022/Proposed Rules page 76267-76268

While the timing and details of a final rule are, as yet, unknown, it is essential that impacted payers need to begin preparing now by ensuring they have a robust FHIR framework in place, a comprehensive longitudinal patient record, and a strong partner to walk beside them on the journey.

CMS 9115-F Interoperability and Patient Access Rule

When the CMS Interoperability and Patient Access Rule became final, InterSystems helped its customers meet the regulation and go beyond it to establish a strategic foundation. Our InterSystems HealthShare® CMS Solution Pack™ is a turnkey product that provides a simplified way to meet the final rule 9115-F requirements.

Learn More About InterSystems CMS Solution Pack

No Surprises Act

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.

Learn More About HealthShare Provider Directory

Value-based Care Requires Payer and Provider Collaboration

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.

Better Care and Coordination Powered by Real-time Alerts

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

Support for the HL7 Da Vinci Project

Using FHIR to streamline priority value-based care use cases, such as prior authorization, between payers and providers is at the core of the HL7 Da Vinci Project. InterSystems supports our customers and their partners so they can succeed in implementing these use cases.

Leverage HL7 FHIR to Streamline Measurement & Enhance Quality

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

Learn More About Clinical Data Integration

Improve Operational Efficiency

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.

Reduce Provider Abrasion and Improve Patient Care

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.

Access to Clinical Data is Key to Efficiency and Other Benefits

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.

Engage and Optimize Network Performance

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.

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