From Mandates to Momentum— a Payer Focused Video Series

Look for:

- A vision that extends beyond regulatory compliance.
- Technical evidence that they’re not just standing up APIs to ‘check-the-box’, and have demonstrable solutions that improve and streamline workflows.
- Plans (and technology) to evolve into new use cases, such as risk adjustment, and care-gap closure that would enhance member and provider satisfaction.

Don’t just ask if they “support FHIR.” Dig deeper:

- Are they based on a FHIR-native architecture?
- Do they actively participate in HL7 Technical Working Groups or help shape industry guidance?
- Do they have experience and expertise with Da Vinci Implementation Guides (IGs), and innovating with CQL?
- How do they leverage AI in their tooling? Do they use a deterministic evidence-based approach, or a probability-based approach?

- Do they offer technical and support services for provider education and onboarding support?
- Can they handle workflows like CDA ingestion and clinical data reconciliation?
- Are their systems battle-tested at scale in real-world implementations?

Look for:

- A data strategy that goes beyond API enablement and into data normalization, enrichment, and deduplication—essential for powering downstream use cases.
- Tools and automation that detect and correct data issues in real-time.
- An architecture that supports comprehensive, longitudinal records and analytics-ready data.

Can the vendor help you activate your data for:

- Risk adjustment and quality programs?
- Real-time prior authorization and care coordination?
- Utilization management or member engagement initiatives?

Is the vendor:

- Leveraging clinical guidelines and industry best practices?
- Able to prove consistent and accurate PA adjudications?
- Able to use an AI approach that resolves systemic biases, and is transparent and auditable?