Stephanie Ngo

Managing Director, Payer and Provider Integration Solutions

Interoperability isn’t a new concept for payers, but there is still a long way to go. Thanks to the 21st Century Cures Act and recent regulatory revisions, including TEFCA, the significance of interoperability is steadily increasing. Collaboration on clinical data exchange between payers and providers is still predominantly optional, but payers are recognizing its value. Clinical data exchange helps break down silos, enhances member care, and can help contain healthcare costs.   

It is becoming vitally important for payers to invest in interoperability strategies to stay competitive and adhere to regulatory compliance. Until recently, payer organizations have been largely content with just checking the compliance box. However, some payers are beginning to go beyond compliance in targeted areas. These payers are meeting, even exceeding, regulations while using interoperability gains to drive business goals.  

To achieve this, payers must identify key business drivers to support investing in interoperability. Here are some ways payers can utilize the resulting data to drive business and build upon their current strategic advantage: 

• Member Onboarding: Both containing costs and providing an excellent member experience start with member onboarding. This is an opportunity to understand new members from a demographic and clinical standpoint. It’s also the time to gather information about services that will be needed to support members, such as network utilization/network adequacy, care management, and other benefit needs.  
• Utilization Management (UM): This has historically been a resource-intensive pain point for the payer-provider relationship. Payers should leverage data obtained from interoperability to reduce expense, friction, and time spent to evaluate UM requests. Data can be used to improve UM via AI and to address the new prior authorization requirements by identifying providers and procedures to be “gold carded.”  
• Value-Based Care Evaluation: As the shift to value-based contracts continues, payers should apply advanced analytics to their data ecosystems. Sharing of timely, actionable insights and performance dashboards improves transparency with provider partners and helps improve collaboration. 
• Risk Adjustment: Many payers are incorporating clinical data into their risk adjustment processes to reduce administrative burden associated with audits. Available data also can be utilized to ensure accurate submissions of member risk, to confirm appropriate clinical documentation, and to surface suspect conditions.  

By leveraging their investment in interoperability, payers can carve out a strategic advantage and create better experiences for providers and members. In the evolving world of healthcare data exchange, payers who use their data to improve efficiency and experiences will come out ahead.