Payers’ Need for Accurate and Timely Healthcare Data Far Exceeds CMS Compliance

Author:  Smile Digital Health |  Published:  February 2, 2021

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New rules from CMS are pushing many payers to invest in their ability to collect, manage and share patient data. However the strategic value of interoperability reaches far beyond compliance with CMS rules; payers have an opportunity to gain significant ROI and come out better prepared to thrive in value based healthcare markets. 

Improving patient data interoperability will enable a world where payers and providers can proactively access and assess healthcare data to give patients more personalized and relevant health solutions and products.

It’s not a pipe dream anymore. Payers can provide the right information to help drive down costs and improve member experiences. While healthcare providers can deliver more innovative services to enhance patient care.  

The challenge here, however, lies in storing and organizing large amounts of data. 

With the right innovation platform, payers can now realize the full potential of data analytics, machine learning and Artificial Intelligence (AI) to get real-time insights into members’ health.

Here’s how it works.

What is the current state of healthcare information management?

Payers, which can range from commercial health insurance plans and third-party health insurance plan administrators to government programs, are now mandated by the CMS and ONC to use open APIs and share patient data with consumers and other payers.

To deliver more accurate health solutions and products, these Interoperability and Patient Access regulations aim to equip healthcare payers, providers and consumers with relevant clinical data through FHIR®-based patient access APIs, provider directories and payer to payer data exchanges. 

All impacted payers must comply before the first deadlines in 2021, so significant work must be doneespecially given the current state of healthcare information management.

At present, claim information analysis is done retroactively. Information is only available in silos and patients have to juggle multiple portals and identities to access the data they need. As such, there is a huge need for payers to have an enterprise-class infrastructure that can adapt and evolve with changes to regulations, standards and consumer preferences. An enterprise class FHIR solution which balances consumer access with granular consent management is a must-have for CMS interoperability compliance, while ensuring you attain analytics-driven insights, cost-savings and improved member experiences.

How can you leverage real-time analytics and data this way?

The new rules set by CMS and ONC offer opportunities for payers to transform relationships with their members and making the goals of value based care a reality. Through the right FHIR server and platform, payers can leverage real-time analytics and data to have free-flowing health information that patients can securely access, providers can use to offer better health outcomes and payers can optimize to reduce costs. 

Why is this important? 

Here are some of the ways real-time data analytics of data can be applied to advance healthcare solutions:

  • With comprehensive data, payers can respond better to the needs of members by identifying healthcare trends as they emerge.
  • Interoperability with providers can facilitate more informed interactions with patients.
  • Being equipped with meaningful insights and analytics can help payers encourage patients to become more proactive with their health like taking eye exams and booking immunizations. This in turn can lead to improvements in quality measures, like HEDIS and Medicare Star Ratings. 
  • Improving quality measures, in turn, leads to competitive advantages in the market, as improved quality measures can result in more reimbursements that can be reinvested into improving member outcomes. Higher ratings also make plans more attractive to both retail and institutional consumers.

What are the valuable advantages of having proper healthcare information management available to payers?

Payers are being challenged to comply on time with CMS and ONC’s Interoperability and Patient Access rules. 

Health plans also have to consider employers worried about controlling costs and members who want personalized digital services and a better overall healthcare experience.

However, with the right healthcare information management in place, payers can create better patterns of interaction and exchange with healthcare providers, other payers, private companies, governments, researchers and health exchangesbuilding more connected health solutions and standards for patients.

Other valuable advantages of having proper healthcare information management: 

  • When it comes to delivering value to patients
    Well structured and normalized data can help payers go from reactive to proactive.  Because payers have been mandated to act as hubs for clinical and administrative data, they have a unique opportunity to help their members manage their health. And with real time analytics, interventions can be made more promptly, both improving health outcomes and reducing plans’ risk exposure.   
  • With relationship to providers
    The interoperability that effective healthcare information management facilitates allows payers to exchange more accurate and relevant information with providers. As a result, both entities can address the broader needs of the health community.

    This kind of collaboration and communication makes prior authorization, HEDIS audits and claim verification more seamless, while improving member  and even population health.
  • In payment processing
    Without automation, incompatible and missing data is far too common. Because of inefficiencies with traditional systems, delays in payments often occur.

    Real- or near-real time data, enhanced by the power of artificial intelligence (AI), takes payment processing to the next level. It enables payment processing to be streamlined, while empowering payers and providers to see better performance with value based contracts.. 

To attain scalable, enterprise-grade implementations that can deliver compliance with CMS interoperability rules, facilitate future innovation and provide favorable ROI in the years to come, it’s crucial to have a high-quality and proven data platform.

The future of healthcare includes Smile Digital Health

At Smile, our goal is  #BetterGlobalHealth. Smile solves the interoperability problem by simplifying and reducing barriers between information and care/outcomes.

Our innovative Smile platform is a commercially maintained clinical data repository built by the maintainers of HAPI FHIRthe open-source reference implementation of the FHIR standard in Java.

Smile can be easily configured to suit your business’ needs. It has enterprise-level scalability and built in security framework and adapters help reduce time-to-market, development costs, and total cost of ownership. 

Smile enables payers to comply with CMS and ONC interoperability requirements while giving patients a more tailored and effective digital healthcare experience.

Request a platform demonstration to learn more.

WEDI Webinar: Understanding the Benefits and Value of Health Information for Payers