The Peak of Collaboration
KLAS’ K2 Collaborative celebrates successful partnerships between payers, providers, and vendors. At KLAS’ fourth annual K2 Collaborative Summit, recipients of the Points of Light Award presented their case studies about successful payer and provider collaborations.
Attendees then voted on the most impactful, scalable, sustainable, and replicable case studies, and the following four collaborations were awarded a Peak Award. This award honors the exceptional teamwork used to address challenges and better serve patients.
Using NLP to Lift the HEDIS Burden
HEDIS reporting is no simple task. Providers face an inundation of requests for clinical data while payers comb through unstandardized notes to determine compliance. AmeriHealth Caritas recognized this burden and set out to make a difference, as found in this KLAS case study. “One of the things that we continue to work toward is how best to collaborate with our providers and reduce the burden on any of our asks as they relate to quality improvement,” says Vandna Bhrany of AmeriHealth Caritas.
AmeriHealth Caritas enlisted the help of ELLKAY, who provided an interoperability platform designed to extract data from Prospect Medical Holding’s EHR. That data was then securely passed to Astrata, who used their natural language processing solution to standardize the data and review the records to reduce AmeriHealth Caritas’ manual burden.
With this collaboration, Prospect Medical Holdings was able to identify a large percentage of their data that needed to be reviewed and review it with an automated process. AmeriHealth Caritas cut their load to less than a fourth of what they had previously been reviewing, and both payer and provider organizations were able to avoid spending time on unnecessary work.
Watch KLAS’ interview with AmeriHealth Caritas, Astrata, ELLKAY, and Prospect Medical Holdings to learn more about this innovative project.
Automating Prior Authorizations with AI and ML
Prior authorizations are another burden shared by both providers and payers. For Henry Ford Health System, the provider organization in this case study, the process of gaining prior authorizations was complex and manual and required over 20 steps. However, the payer organization in this case study was struggling with the challenge of incomplete submissions and manual information requests. Both sides were dealing with the pains of denials and appeals.
To solve this problem, Henry Ford Health System and the payer organization teamed up with Rhyme to automate the retrieval of data from Henry Ford Health System’s EHR, trigger the submission of admission cases, and standardize the data using AI and ML.
As a result, this collaboration has already saved Henry Ford Health System hours of provider time each week, increased their automation and electronic decision-making, and reduced turnaround time. Participants noted the importance of an aligned understanding of business and technology needs, trust, documentation, and adaptability.
Read the case study to learn more about the results of this new approach.
Leveraging FHIR APIs to Open the Prior Authorization Process
More than one Peak Award winner addressed the issues of prior authorization, a relevant concern in healthcare today. As the healthcare industry moves more toward value-based contracting, the requirements for prior authorizations will also adjust, highlighting the need for more efficient processes.
Cambria Health Solutions, a payer organization operating under Regence BlueCross BlueShield, worked with UC Davis Health and eHealth Exchange to create a secure, common space for data exchange between providers and payers via FHIR APIs. Using the DaVinci implementation guides, the organization was able to bring more automation and real-time communication to the process, ultimately benefiting patients and creating something closer to a plug-and-play environment for future players.
Previous prior authorization data exchange required both providers and payers to buy the same technology—an impossible feat considering the sheer number of payers each provider organization interacts with. But by using FHIR APIs, stakeholders were able to “leverage industry standards, implementation guides, and semantic interoperability to connect with partners in a much easier and more robust way than they may have in a legacy interoperability space,” says Michael B. Marchant, previously the director of system integration and health information exchange at UC Davis Health.
Watch KLAS’ interview with Cambria Health Solutions, UC Davis Health, and eHealth Exchange to learn more about the impacts of this project.
Using AI to Identify and Meet SDOH Needs
In this case study, Sentara Health recognized that members of their diverse patient population were experiencing negative SDOH factors, such as housing or food insecurity, that were affecting their health engagement. These members were difficult to reach and had care gaps, which factors led to overuse of the ED and decreased wellness.
Sentara Health partnered with N1 Health to use AI to collect consumer information and predict risks and SDOH needs. Sentara Health called their at-risk members to offer benefits to make healthcare possible, connected them to clinical case managers when necessary, and monitored their health over time. “When you have that conversation, then you start to build trust, and then the members are willing to engage more,” says Traci Massie of Sentara Health.
Through this partnership, Sentara Health and N1 Health learned the importance of agility and leadership buy-in as they realized a 6% increase in member retention, a 4%-5% increase in the number of members willing to close care gaps, and other ROI factors. “We had a shared vision,” says Michael Hinkson of N1 Health, and together, N1 Health and Sentara Health were able to help members become more engaged, which leads to better long-term health.
Watch KLAS’ interview with Sentara Health and N1 Health to learn more about this groundbreaking project.
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