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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 organisations and settings
  • Enhance quality and streamline measurement
  • Engage and optimise 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

Driving Interoperability, Improving Care Coordination, Reducing Burden and Empowering Patients (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 patients 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 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.

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 hospitalisations. 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 authorizsation, 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. Recognising 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

Improve Operational Efficiency

Which manual payer/provider process cries out for automation? If you said prior authorisation you’re not alone. The prior authorisation 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 authorisation is $3.68, compared to $0.04 per electronic prior authorisation, 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 authorisations – 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 authorisation and utilisation management, include compliance with state or federal programs such as lead screening, and eliminating the HEDIS chart chase.

Engage and Optimise 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.

Related Resources

Jul 20, 2023
Leveraging FHIR for Payers
The implementation of the CMS Interoperability rule (9115-F) presents an opportunity for payers to leverage their investment in FHIR infrastructure and aggregated data beyond just regulatory compliance.
May 02, 2023
In the greater New York City area, Healthfirst, a not-for-profit, hospital-sponsored health plan and pioneer in value-based care, recognized the need for collaborative data exchange with providers for quality and improved member outcomes.
Aug 09, 2023
KLAS Research: Points of Light Case Study
Improving the Speed and Transparency of Authorizations through FHIR API–Enabled Data Sharing
Jun 02, 2022
Healthcare Payers
Learn how NYC-based Healthfirst has used the clinical data from their provider network, to monitor quality measure performance and use that data as a source of numerator and denominator.
Aug 12, 2022
WEDI Presentation
The No Surprises Act (NSA) came with many new requirements for payers and providers. Some of those provisions have implications for how payers and providers share data. The Act requires providers to share advance cost estimates and estimated out-of-pocket costs for specific services with patients. Payers and their provider partners also need to make sure they have accurate provider directories so that patients aren’t “surprised” when they receive a bill for an out-of-network provider they thought was in network.
May 25, 2022
FHIR - HL7 Da Vinci
HL7’s Da Vinci project is using HL7 FHIR to better connect payers and providers and address prior authorization.

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