The Challenges Addressed by K2 Collaborative Points of Light 2024 - Cover

The Challenges Addressed by K2 Collaborative Points of Light 2024

Each year, KLAS celebrates the successful payer, provider, and vendor partnerships that are enhancing healthcare outcomes with the Points of Light awards. We look forward to listening to many of these Points of Light collaborations during the upcoming K2 Summit.

In 2024, the five main challenges addressed among the 22 case studies are value-based care, prior authorization, payment integrity, release of information, and remote patient monitoring & care management. For ease of reference, the rest of this blog is organized by those five challenges. However, it is also important to note that within these areas, many collaborations also had an aspect of interoperability or clinical data exchange.

Read on to learn more about each case study’s specific situation and what the partnerships did to address the challenges. For a quick look at the outcomes of each one and to learn more about the overall learnings from the Points of Light, I recommend taking a look at the executive overview of the Points of Light 2024. For more complete details, please review the full report or check out the links below for individual case studies.

Value-Based Care Challenges

The value-based care initiatives worked to improve cost containment and patient engagement and help with accurate CMS reimbursements.

Case Study 2: Empowering Community Pharmacists to Contribute to Value-Based Care through App & Incentive Program

Poor medication adherence leads to adverse health outcomes for patients, and pharmacists lacked the needed insights to help. Working with local pharmacies, this collaboration created a value-based pharmacy partnership program to improve Medicare Advantage members’ medication adherence and satisfaction by integrating actionable insights into pharmacy workflows.

Case Study 3: Reducing Costs & Adverse Patient Events by Closing Gaps in Transitions of Care

Transitions of care are a pain point because of the many moving parts that can lead to clinical data loss or issues in patient care coordination. Stakeholders created a solution that identifies when care transitions are occurring and provides the care team with appropriate clinical information.

Case Study 4: Improving Quality Metrics & Outcomes for Medicare Advantage Patients through Real-Time Information 

After patients are discharged from the hospital, a lack of timely patient data often prevents provider organizations from aiding in appropriate care coordination. To help, Privia Health and Humana worked with Bamboo Health to increase the visibility of MA patient data to close care gaps, improve CMS Star Ratings, and improve patient outcomes.

Case Study 5: Automating Release of Information to Support Quality Improvements

While payers need timely access to accurate clinical data, the release of information process is often cumbersome for providers. The partners here tackled this by implementing technology that automated the chart-retrieval process and helped reduce the providers’ administrative burden.

Case Study 7: Closing Care Gaps for HEDIS Measures through Natural Language Processing

HEDIS reporting requires accurate data, but payer and provider organizations often lack visibility into the complete picture of patient/member compliance with Medicaid measures. So the stakeholders put together a continuous HEDIS review workflow to triage cases and close any care gaps.

Case Study 11: Using EOB Data to Create Complete Clinical Profiles & Close Care Gaps during In-Home Wellness Assessments 

A lack of awareness of the socioeconomic factors faced by members prevents payer and provider organizations from fully caring for their members/patients. The payer and provider organizations in this case study established interoperability and created data transparency for home health providers around these factors.

Case Study 12: Using Data-Driven Process Improvement Initiatives to Improve Efficiency & Close Care Gaps for Preventive Screenings

Many patients in this study were not receiving or following through with referrals for necessary preventive screenings like breast cancer, colorectal cancer, or diabetic retinopathy. The provider and payer organizations collaborated with CareAllies to establish a better referral workflow.

Case Study 13: Improving the Completeness & Accuracy of Risk Scores for Medicare Advantage patients through Clinical Data Sharing

If MA patients are seen by providers other than their primary care physician (PCP), the PCP is frequently unaware of the diagnoses and data from that visit. Working with Epic, the payer and provider in this collaboration transferred clinical data from Epic Payer Platform into the provider’s patient charts.

Case Study 20: Closing HCC Coding Gaps through an Information Retrieval Assistant 

Provider organizations don’t always have the necessary data or training to be able to accurately complete hierarchical condition category (HCC) coding and close coding gaps. To solve this, the stakeholders seamlessly transferred payer information into clinician workflows and implemented technology to flag gaps in clinician documentation.  

Case Study 21: Leveraging AI-Driven Personalization & Virtual PCPs to Modernize Member Engagement & Risk Stratification Accuracy

Changes in the health plan market unexpectedly took Cigna membership from 350,000 members to 1 million. Cigna, MDLIVE, and N1 Health worked together to proactively reach out to new members and to help schedule annual wellness visits for them.

Case Study 22: Transforming Medicare & Medicaid Member Engagement through AI-Powered SDOH Risk Prediction & Personalization

Social and environmental factors like unsafe housing or food insecurity can worsen health and lead to patients overusing the ED. Sentara Health partnered with N1 Health to identify SDOH barriers using AI/ML consumer data; they proactively engage members with specific benefits and provide grant assistance to those with high risk of housing insecurity.

Prior Authorization Challenges

Collaborations under this category sought to streamline the prior authorization process in various ways such as leveraging AI, interoperability, or clinical decision support.

Case Study 1: Improving Prior Authorization Efficiency through Automated, Touchless Data Exchange

A lack of integration made the prior authorization process massively inefficient and manual for organizations in this study. Collaborators partnered with their vendor, Rhyme, to connect the payer and provider workflows and share prior authorization data in real time.

Case Study 6: Using API Technology to Automate Managed Care Referral Authorizations

The process of authorizing managed care referrals could be a time-consuming process for providers, health plans, and patients. To help, these stakeholders partnered to combine API technology with robotic process automation to automate the referral process and give transparency on referral status.

Case Study 8: Streamlining Prior Authorization though Comprehensive, Real-Time Data Exchange

Prior authorizations frequently cause friction between payers and providers because of the back-and-forth involved in these requests. enGen worked with both the payer and provider organizations in this study to create a solution for utilization, case, and disease management for better data transparency.

Case Study 10: Reducing Administrative Burden & Improving Patient Outcomes through Bundled Prior Authorization Approvals

OrthoTennessee patients who had received knee surgery experienced a delay in care because of a lengthy prior authorization process. Working with Cohere and Payer Organization 10, this provider partner bundled prior authorizations into one transaction.

Case Study 14: Easing Administrative & Operational Burdens through Electronic Prior Authorization

The stakeholders here were experiencing a large payer/provider administrative burden and delayed patient care due to the complexity of prior authorizations. Via Epic Payer Platform, they created an electronic prior authorization process to automate prior authorization requests.

Case Study 15: Reducing Administrative Burden & Time to Care by Automating Prior Authorization

Gaining prior authorization for inpatient stays was a time-consuming process for the provider in this study. But on the payer side, they were frequently dealing with incomplete submissions. Working with Rhyme, they streamlined the prior authorization process using automatic data sharing.  

Case Study 16: Using FHIR Standards to Streamline Prior Authorization Management & Improve Patient Care

As has been noted, the manual nature of prior authorizations invariably creates an administrative burden for both payers and providers. This partnership automated the process using Availity to connect payer and provider solutions and allowed a more seamless data exchange.

Case Study 18: Automating Prior Authorizations through Networked FHIR Connections

The complexities of data sharing often create high costs and a lot of administrative work for organizations. UC Davis Health and Regence partnered with eHealth Exchange to initiate easier, faster data sharing with FHIR technology.

Payment Integrity Challenges

Case Study 9: Reducing Administrative Burden by Resolving Overpayment Claims via a Third-Party Partner

A high volume of communication about potential overpayment claims caused struggles for the payer and provider organizations involved in this study. To resolve the problem, they worked with TREND Health Partners to review any potential overpayments and facilitate communication between the two organizations.

Release of Information Challenges

Case Study 17: Streamlining Release of Information through Automated Requests

Release of information requests required a lot of manual effort and created more administrative burden for all stakeholders. To help, they worked with Epic to bundle and then automate requests for clinical data.

Remote Patient Monitoring & Care Management Challenges

Case Study 19: Expanding Care Management for Rising-Risk Populations through Deviceless RPM

Typically, payer and provider organizations have tools and data to identify and provide care for high-risk patient populations. Cases where patients have rising risk, however, are harder to identify and provide care for. To better monitor rising-risk patients, stakeholders in this study used Lightbeam Health Solutions’ deviceless remote patient monitoring system.

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