K2 Collaborative Summit 2023
Fostering Trust and Collaboration between Payers and Providers

The Current State: How Do Payers and Providers View Each Other and the Market?

To understand how payers and providers view the current healthcare market, KLAS asked conference attendees to complete a pre-summit survey on issues regarding the industry’s shift to value-based care (VBC). Further, payer and provider organizations were given the opportunity to anonymously rate the performance of their payer or provider partners.

Perceptions of Shift to VBC Have Changed since 2019

Prior to the summit, participants were asked about the following issues regarding the healthcare industry ’s shift to VBC:

Key insights from the data:

• Fewer provider attendees agree that a move to VBC would do more for payer/provider cooperation than anything else. VBC is viewed as the preferred environment for payer/provider collaboration, but this year, there is some lack of alignment between payer, provider, and vendor perceptions. Provider attendees are less optimistic than in the past (40% in 2023 compared to 70% in 2022) that moving to VBC would be the best thing for improving payer/provider cooperation. Provider organizations say they are struggling to remain financially viable as they adapt to changed care-delivery methods and that it can be difficult to make the infrastructure and data management upgrades required for VBC payment models. Additionally, provider respondents report that an increase in the documentation payers request has been coupled with a notable decline in payer responsiveness to appeals, inappropriate denials, inappropriate claims adjudication, and refund requests.

“The client, provider, and payer are all out of alignment, and that adds to the complexity of the VBC model.“ —Summit attendee from payer organization

• Distrust between parties is growing in fee-for-service models. The data shows that across the board there has been a decline of at least 12 percentage points in respondents who report that collaborations of high trust are possible in a fee-for-service environment.
• Most 2023 attendees agree that in 10 years, VBC will be the main financial and care-delivery model. However, they don’t believe it will be a silver bullet to solving payer/provider friction, acknowledging that VBC payment models come with additional stressors. For example, the technology stack needed to support VBC is vastly different to that needed in a fee-for-service world. With VBC, meeting CMS regulations and maintaining compliance is a large administrative and operational burden requiring bidirectional data sharing between payers and providers.
• Provider confidence that HIT vendors play a key role in building payer/provider alignment has dropped from 86% to 60%. Interestingly, payer confidence is higher than it was in 2022 (92% compared to 75%). HIT vendor agreement has remained the same.

Payer/Provider Measurement

As part of the K2 Collaborative’s ongoing mission to help facilitate successful payer/provider collaborations, provider and payer organizations have been invited to anonymously rate the performance of their respective payer and provider partners. Provider organizations were asked to rate the top commercial payers their organization engages with. To date, KLAS has collected, aggregated, and analyzed ratings from 30 provider organizations across seven states. KLAS also interviewed 8 payer organizations across multiple states, who were asked to aggregate their provider experience into one rating based on overall provider performance per question. The goal of these performance measurements was to:

• Provide actionable insights that improve understanding of the payer/provider landscape: Respondents were asked to rate their payer or provider partner’s proactivity in building trust, the timeliness of their communication, and their ability to provide a positive member/patient experience. Other questions focused more on operations and asked respondents to rate their partner’s transparency with policies and procedures, agility and ability to improve governance structures, facilitation of bidirectional data sharing, and helpfulness in reducing manual processes.
• Capture ratings that KLAS can use to provide industry benchmarks and insights
• Enable and accelerate dialogue between payers and providers: Performance measurements, benchmarks, and insights can function as a facilitating mechanism that allows mutual learning and understanding of each other’s needs, driving actionable change and improved collaboration. KLAS’ intent is to create an environment where payers and providers can address opportunities together and improve the status quo through regional engagements.

Building Trust: What Can Payers and Providers Do to Improve Collaboration?

Pre-Summit Survey: Payer and Provider Perceptions of Trust-Building Activities

Taking Action: Activities Payers and Providers Say Would Increase Trust

At the summit, attendees participated in tabletop discussions, where payers and providers shared actions the other party could take to increase trust. Payers and providers agree that partnerships of trust assume good intent, include open, honest discussions, and encourage both parties to be agile in tackling hurdles.

Where to Start? Places Where Payers and Providers Are Mutually Aligned

The goal of the 2023 summit was to identify and understand areas of success as well as areas of opportunity in the payer/provider relationship. Summit attendees brainstormed areas in which the two groups are aligned and then discussed how each area could be addressed.

“There is so much room in this world where payers and providers want the same thing but have not been able to pull it off.“ —2023 summit attendee

Summit attendees provided insightful feedback on areas of alignment. The most-mentioned themes are listed below with suggestions on how to improve alignment.

• Interoperability and bidirectional data sharing between payers and providers is not effective or efficient
• Some payers have siloed, underperforming technology that is difficult to connect with provider workflows. In some cases, technology can be upgraded, but sometimes operational processes between payers and providers also need to be improved to reduce administrative fatigue on both sides. Even if the discussion is not solution driven, understanding of processes can help improve efficiency.
• Mutual trust and understanding of data-sharing rules and definitions is required. Building a dictionary of standardized terminology to define things such as readmissions and what constitutes an informational request as opposed to a denial would create mutual understanding of care activities.
• Processes could be improved by organizing payer/provider governance boards consisting of small groups overseeing targeted interoperability tasks.
• Payers and providers should consider embracing TEFCA and FHIR standards.
• Processes and operations need to be standardized
• Payers and providers need to standardize processes for inputting and cleaning data and clearly attributing patients. This will reduce record duplication and improve data exchange. X12 was expected to assist with this standardization, but now the sentiment among payers and providers is that APIs or machine learning might be helpful.
• Payers and providers need to update internal siloed workflows first and then align and collaborate more between business models.
• Payers and providers should agree in their contracts to adopt either Milliman or InterQual criteria when making utilization management decisions. This will help standardize processes by having a consistent set of guidelines and rules to assess and determine the necessity and appropriateness of medical services. This standardization can streamline processes, improve communication between payers and providers, and ensure consistency in decision-making related to healthcare utilization.

“There are shared incentives to work together. Missed opportunities in the past are starting to open eyes on both sides.” —2023 summit attendee

• Due to confidentiality concerns, measurement of financial ROIs has been challenging. What other KPIs can become accepted industry standards for measuring payer/provider performance? 
• Ideally, KPIs would be defined by a federal mandate. For now, KPIs need to be grounded in payer and provider goals. Attendees suggested that care utilization metrics be used.
• Metrics could be defined by the type of contract (i.e., fee-for-service versus value-based care contracts).
• Payers and providers suggested sharing the project plan and road map, then establishing agreed-upon KPIs based on efficiency standards or metrics, such as call volumes and turnaround times for prior authorizations and follow-up appointments.
• Operational or process measurements could be used as KPIs and could include the first-pass payment resolution rate, turnaround time, and appeals volume.
• Attendees suggested having satisfaction surveys to measure the provider and patient experience.
• Payers and providers need to be more aligned and engaged in VBC to create a win-win scenario 
• Currently, VBC metrics vary between payers, which creates administrative churn for providers.
• Health systems’ core technology has not been configured to track the metrics needed for value-based agreements. Third parties can be used to understand these metrics. Additionally, active dialogue between different operating siloes within health systems will help with understanding risks and operations around VBC.
• Providers often need to upgrade their technology stacks to support VBC agreements. For example, they may need to implement or update population health management technology.
• Holding standard, recurring meetings that include representatives from all relevant payer and provider departments will ensure all voices are heard, streamline operational processes, and help both parties overcome barriers.
• Proactively incentivizing provider frontline staff to close care gaps will reduce employee burnout and improve provider staff retention.
• From the provider perspective, payer requirements, rules, and policies can be a moving target. How can these constant updates and changes be addressed?
• Providers need to understand the reasoning behind things like claims denials and DRG downgrades. Improving communication and having clear explanations from payers is imperative for providers to understand and address these pain points. It was suggested that issues such as use of variable codes could be solved by streamlining operational standards for claims teams, contracting teams, and IT teams across payer and provider organizations.
• Attendees suggested that QR codes could be added to patient insurance cards linking directly to all relevant insurance information, including coverage, copay, and so forth. This would reduce administrative churn and give patients and providers an informed understanding at the point of care of what patients qualify for relative to their health plan.
• Payer attendees suggested establishing a common set of rules across payers so that if members switch plans, their data would be understandable to their new payer. Medicare has some standardization of guidelines. Attendees suggested having federal guidelines or utilizing the standard offering list currently being developed by the National Association of Health Plans (AHIP).

Next Steps for Payers and Providers

Based on the insights and suggestions that came from the candid conversations about building trust and areas alignment, payers and providers can work together by:

• Identifying the areas where they are individually most capable of taking action: It will take time to resolve existing issues; however, payers and providers believe working toward a solution is worth the effort and investment in the long run.
• Mutually deciding on areas of opportunity where both groups feel most ready to act: This could involve formalizing an action plan or road map and prioritizing which obstacles will be tackled first. This formalized, collaborative action plan will build partnership and trust.
• Holding themselves and the other party accountable to next steps through regular, follow-up communication between the right stakeholders
• Having agreed-upon measures of success: Payers and providers do not necessarily need ROI measures of success but rather process-driven or operationally driven measures of success that can hold parties accountable for progress in reducing friction and improving areas of opportunity.
• Building momentum to tackle additional challenges by celebrating successes and taking advantage of lessons learned

Our goal is to build more trust and collaboration so that payer and provider organizations have a better foundation from which to tackle tough missions together. KLAS has observed that both parties recognize the need for better collaboration.

Next Steps for KLAS

• Encourage and facilitate regional engagements with payers and providers: KLAS will continue to work closely with payer and provider organizations in specific regions to facilitate the building of collaborative partnerships that drive action and inform change. KLAS brings region-specific data to the engagements with the goal of facilitating constructive, action-driven dialogue that targets areas of alignment, opportunity, and scope. Regional engagements have follow-up meetings that hold payers and providers accountable for agreed-upon actions and reduce payer/provider friction.

“Discussion is where things get better, but who can sit in the middle and facilitate? Someone needs to be able to drive those discussions forward without personal interest.“  —Summit attendee from payer organization

• Continue with payer/provider performance measurement: We will continue to broaden our data collection by interviewing payers and providers across the country as we expand our regional efforts to understand the payer/provider experience and identify strengths and opportunities for improved efficiency.
• Help payers align their road maps to provider needs and abilities: As a third party, KLAS can impartially facilitate regional engagements during which payers and providers can align their strategic plans and road maps. There is a lot of payer investment in improving the provider and patient experience. These solutions often aren’t fully adopted, preventing the desired outcomes.
• Facilitate K2 payer/provider virtual forums: Held on a bimonthly basis, these forums would enable payers and providers to discuss relevant issues; share insights, successes, and areas of opportunity; and brainstorm ways to overcome barriers.
• Continue to recognize the Points of Light collaborations and award recipients: We will continue to highlight the provider organizations, payers, and technology vendors who have found success via partnership and collaboration. We will consider impact, innovation, creativity, scalability, and replicability to determine how these collaborations are improving the patient experience and reducing friction. To submit your story, please email us at POLCollaboration@klasresearch.com.

Details on 2023 Points of Light Recognition

As part of the K2 Collaborative, KLAS celebrates successful collaborations between payers, providers, and HIT vendors through the annual Points of Light recognition. In 2023, KLAS recognized 25 such collaborations. All Points of Light collaborations were given the opportunity to present at the K2 Collaborative Summit, where they presented an overview of their project and the outcomes achieved. Two additional collaborations slated to be highlighted in the 2024 Points of Light also presented. To highlight the collaborations with the greatest impact, summit attendees selected three collaborations from among the presentations to win a Peak Award, based on the projects’ efficiency improvements, scalability, achieved outcomes, and replicability. See the Points of Light 2023 report for in-depth case studies of each collaboration.

Peak Award Recipients

Case Study #8: Using Real-Time Care Alerts to Improve PCP Visibility of Inpatient Data

Healthcare organization: Innova Primary Care
Payer organization: BlueCross BlueShield of Alabama
Technology partner: Secure Exchange Solutions

Executive Summary: Follow-up from a primary care physician (PCP) can be critical for successful outcomes for patients who have recently been admitted or discharged from the hospital or visited the ED. However, PCPs often lack visibility into their patients’ inpatient and ED care data, preventing them from closing these care gaps. After receiving feedback about this challenge from PCPs, the payer organization in this collaboration proposed embedding care alerts directly into providers’ workflows, enabling them to reduce readmissions, ED visits, and the administrative burden for provider organizations.

Outcomes: Reduced administrative burden for provider organization due to having access to real-time data at the point of care. Improved connectivity between local hospitals and PCPs. Reduced readmission rates and ED visits, with an associated reduction in actual vs. expected ED costs.

Case Study #18: Streamlining the Exchange of Supplemental Data

Healthcare organization: Anonymous
Payer organization: Humana
Technology partner: Moxe

Executive Summary: To be successful in value-based contracts, payer and provider organizations need a complete view of patient data that allows them to accurately assess patient risk. However, extracting this data from the EMR and sending it to the payer is often a manual, labor-intensive process for the healthcare organization, while processing all that data to find the relevant information is equally burdensome for the payer organization. The collaborators in this case study automated the process, leading to increased efficiency and more accurate quality and risk adjustment submissions.

Outcomes: Increased efficiency and reduced workload for provider organization’s HIM department, help desk department, and technical support department, allowing resources to be reallocated to other tasks. More accurate HEDIS metrics for the payer organization, improving financial incentives for them and the provider organization.

Case Study Slated for 2024 Publication: Automating the Exchange of Prior Authorization Information in an Integrated, Machine-First, Real-Time Way

Healthcare organization: Advocate Aurora
Payer organization: UHC/Optum
Technology partner: Rhyme

Executive Summary: Rhyme uses an approach to solve prior authorization called LiveAuth—a platform that stitches providers and payers into a single, seamless workflow with intentionally touchless authorizations between all participants. Rhyme’s LiveAuth GPA measures provider satisfaction and gives payers and providers a common understanding of progress in eliminating abrasion.

Outcomes: The partnership reduced and eliminated many wasteful, manual touches on prior authorization submissions, resulting in a touchless decision rate of 77%, with an overall LiveAuth GPA score of 2.65. LiveAuth GPA is a new metric that measures provider satisfaction with prior authorization processes on a per payer basis. It is measured on a 4.0 scale and grades the number and types of provider touches required to complete a prior authorization case. Rhyme proved that Advocate Aurora realized meaningful administrative time savings and UHC created significant, positive change to both provider and member satisfaction.

2023 Points of Light Recognition

Summaries of the 2023 Points of Light case studies are shared below to illustrate the art of the possible. Such collaborations require tremendous commitment and effort from all parties.

Collaboration 1: Simplifying the Administrative Process through Shared Clinical Data

Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: Epic

Executive Summary: Seeking to ease the administrative burden created for both sides by manual denial and prior authorization processes, the collaborators in this case study first identified common pain points and then established shared goals. One of their initial projects was to reduce the need for Payer Organization 1’s clinicians to request additional information from Healthcare Organization 1 during claims review. To accomplish this, they utilized the Clinical Document Exchange within Epic Payer Platform to give the clinicians in-workflow access to members’ clinical data. The results have been improved efficiency, a significant reduction in denials, and a more trusting relationship.

Collaboration 2: Improving the Speed and Transparency of Authorizations through FHIR API–Enabled Data Sharing 

Healthcare organization: UC Davis Health
Payer organization: Anonymous
Technology partner: InterSystems

Executive Summary: Prior authorizations for referrals and clinical procedures are widely acknowledged as a significant pain point for all involved parties—payers, providers, and patients. Using implementation guides from HL7’s Da Vinci Project, the collaborators in this case study created bidirectional data exchange through a FHIR API that enables an automated, in-workflow authorization process. The pilot use cases have been successful, achieving improved efficiency, reduced costs, and—most critically—more timely care and improved patient outcomes.

Collaboration 3: Enabling Bidirectional Data Sharing to Reduce Record Requests for Managed Care Audits 

Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: Ciox Health

Executive Summary: To meet CMS requirements for the submission of risk adjustment data and ensure they are being fully reimbursed by CMS, payer organizations need increasingly specific coding information, and these requests for information can put undo administrative burdens on provider organizations. Seeking to increase the payer organization’s access to needed information without increasing the provider organization’s workload, the collaborators in this case study established an API that enables an automated, standardized retrieval process for records that the payer organization needs to complete managed care audits.

Collaboration 4: Combining Payer & Provider Intelligence by Incorporating Claims Data at the Point of Care 

Healthcare organization: Baptist Health
Payer organization: Humana
Technology partner: Epic

Executive Summary: Claims data from payer organizations can give providers a more comprehensive view of a patient’s clinical history and thereby improve the quality of care they are able to deliver. Yet incorporating this information at the point of care can be expensive and challenging. To tackle this problem, the collaborators in this project worked to map the payer organization’s claims data so that it could be incorporated into provider workflows in real time at the point of care.

Collaboration 5: Streamlining Utilization Review by Sharing Real-Time Clinical Data 

Healthcare organization: Anonymous
Payer organization: Humana
Technology partner: XSOLIS

Executive Summary: A lack of interoperability was preventing the collaborators in this case study from being able to have a shared, comprehensive clinical view of a patient’s health status, resulting in preemptive claims denials and administrative churn. By implementing a shared case review platform backed by AI and predictive analytics, they were able to reduce manual work and improve efficiency for both sides. While gaining buy-in was initially a hurdle, the project’s outcomes have proven its value.

Collaboration 6: Using API and RPA Technology to Optimize Claims Monitoring

Healthcare organization: Piedmont
Payer organization: UnitedHealthcare
Technology partner: Waystar

Executive Summary: To reduce the manual work associated with claims monitoring, the partners in this case study collaborated to combine API technology from the payer with robotic process automation (RPA) technology from Waystar. Claims statuses are then normalized and delivered directly into the healthcare organization’s EMR workflows, resulting in greater claims visibility and a reduced administrative burden for all parties. As a result of this collaboration, the healthcare organization has also seen reduced denials and faster payment collection.

Collaboration 7: Supporting Value-Based Care Initiatives with Cost and Utilization Data

Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: Health Catalyst

Executive Summary: The provider and payer organizations in this collaboration recognized that progress in their population health and value-based care initiatives would not be possible without each organization having access to comprehensive patient and member data. Embracing their shared goal of enabling better managed care, the organizations worked with their technology partner to aggregate claims and clinical data and utilize analytics to gain insights into cost, utilization, quality, network, and performance metrics.

Collaboration 8: Using Real-Time Care Alerts to Improve PCP Visibility of Inpatient Data

Healthcare organization: Innova Primary Care
Payer organization: BlueCross BlueShield of Alabama
Technology partner: Secure Exchange Solutions

Executive Summary: Follow-up from a primary care physician (PCP) can be critical for successful outcomes for patients who have recently been admitted or discharged from the hospital or visited the ED. However, PCPs often lack visibility into their patients’ inpatient and ED care data, preventing them from closing these care gaps. After receiving feedback about this challenge from PCPs, the payer organization in this collaboration proposed embedding care alerts directly into providers’ workflows, enabling them to reduce readmissions, ED visits, and the administrative burden for provider organizations.

Collaboration 9: Speeding Up Prior Authorization Workflows Using Automated Communication

Healthcare organization: Ochsner Health
Payer organization: Humana
Technology partner: Epic

Executive Summary: Submitting and following up on requests for prior authorization is often a manual, time-consuming process, creating administrative burden for both payer and provider organizations and potentially delaying needed care for patients. The stakeholders in this collaboration worked to streamline the process by automating the submission and follow-up for authorization requests, enabling providers to complete these tasks from within their EMR workflow. Results include faster turnaround times, reduced administrative workload, and fewer denials.

Collaboration 10: Modernizing Interoperability to Improve Data Exchange across the Care Continuum

Healthcare organization: MediSys Health Network
Payer organization: Healthfirst
Technology partner: Hyphen

Executive Summary: Having an incomplete view of their patients’ or members’ health journey is a challenge that payer and provider organizations share. To modernize interoperability and improve data exchange for both parties, the collaborators in this case study designed, developed, and implemented a software solution that bidirectionally exchanges accurate, up-to-date information on patient risk scores, medication adherence, and care gaps, making this information available within the EMR workflow. The automation has improved patient care and satisfaction and reduced the administrative burden for both the payer and provider.

Collaboration 11: Using Deviceless RPM to Improve Care Management and Reduce Readmissions

Healthcare organization: Carle Health
Payer organization: Health Alliance
Technology partner: Lightbeam Health Solutions

Executive Summary: Hoping to provide improved care management for individuals with high-risk chronic conditions, the collaborators in this case study launched a program aimed at providing deviceless remote patient monitoring for recently discharged individuals with hypertension, COPD, or congestive heart failure. If patient-entered data is outside the normal thresholds, virtual care navigators receive real-time alerts and can intervene to prevent the patient’s condition from deteriorating. Outcomes include reduced ED visits and readmissions as well as lower costs.

Collaboration 12: Improving Patient Understanding of Financial Responsibility by Simplifying the Payment Experience

Healthcare organization: Allegheny Health Network
Payer organization: Highmark Health
Technology partner: Cedar

Executive Summary: Attempting to interpret a medical bill can be a frustrating experience for even the most informed patients, and the collaborators in this case study knew that this systemic problem could be solved only through a joint effort. The partners integrated billing information from the provider organization with claims, HSA, and EOB data into one platform. The platform provides patients/members with more transparency related to their financial responsibility and gives them options for immediate payment or, if needed, helps them select a payment plan. User satisfaction with the system is nearly 90%, and patient-responsibility payments have increased.

Collaboration 13: Automating Prior Authorization Determinations with AI

Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: Olive

Executive Summary: The prior authorization process can be a frustrating experience for all involved—patients, payers, and providers. The collaborators in this case study utilized AI technology to automate tasks at every step of the process—from submission to final decision. Regular communication between the collaborators helped make the implementation successful, and reported results include less manual work for the payer and provider organizations, faster authorization decisions and thus faster access to care, and fewer denials.

Collaboration 14: Leveraging HL7 FHIR Interoperability Standards to Automate Prior Authorizations

Healthcare organization: MultiCare Connected Care
Payer organization: Regence
Technology partner: MCG Health

Executive Summary: Managing the prior authorization process is a labor-intensive undertaking that requires significant resources from both provider and payer organizations. This manual process can delay patient access to care and potentially lead to serious adverse events. Beginning with a small pilot, the collaborators in this case study worked with their technology partner to automate the submission of authorization requests from the EMR, including all necessary clinical information, and receive decisions in near real time. The new process has eliminated manual processes, reduced patient wait times, and eased the administrative burden.

Collaboration 15: Aggregating Clinical and Claims Data to Create a Unified Patient Record

Healthcare organization: Anonymous
Payer organization: CareFirst BlueCross BlueShield
Technology partner: MRO

Executive Summary: Patient data often exists in silos, leaving healthcare organizations with poor visibility into care given at other facilities and preventing payer organizations from being able to access a full view of their members’ clinical history. To give both parties a more robust clinical picture of each patient’s care journey, the collaborators in this case study invested in technology to map non-standardized CCD data into one unified medical record that gives both the payer and the provider the ability to track patients across settings and over time. The project has streamlined data-exchange processes and improved performance in quality measures.

Collaboration 16: Automating the Exchange of Clinical Data

Healthcare organization: Prospect Medical Holdings
Payer organization: Anonymous
Technology partner: ELLKAY

Executive Summary: Historically, the payer organization in this collaboration lacked easy, real-time access to their members’ complete clinical data, not just claims-specific information from the EMR, and had to request this information from the healthcare organization in order to inform their HEDIS quality measures and NCQA submissions. To reduce the administrative burden for both organizations, the collaborators in this case study implemented ELLKAY’s Clinical Data Exchange technology to automate the exchange of clinical data, resulting in faster release of information, improved data security, and more accurate quality measure submissions, contributing to increased revenue for both organizations.

Collaboration 17: Improving Medication Adherence among High-Risk Populations

Healthcare organization: Valley Organized Physicians
Payer organization: Cigna
Technology partner: CareAllies

Executive Summary: Vulnerable and underserved populations face a variety of barriers that can make it difficult for them to adhere to their prescribed medication regimens, and the impacts of non-adherence—in terms of health outcomes and costs—can be severe. Low medication adherence was a particular problem for the healthcare organization in this case study, whose patient population covers one of the most vulnerable and underserved zip codes in the country. To encourage better adherence among high-risk individuals, this organization collaborated with a payer organization and value-based care partner to identify patients in need of additional support and help resolve their barriers to adherence. Results include better health outcomes and higher CMS Star ratings.

Collaboration 18: Streamlining the Exchange of Supplemental Data

Healthcare organization: Anonymous
Payer organization: Humana
Technology partner: Moxe

Executive Summary:  To be successful in value-based contracts, payer and provider organizations need a complete view of patient data that allows them to accurately assess patient risk. However, extracting this data from the EMR and sending it to the payer is often a manual, labor-intensive process for the healthcare organization, while processing all that data to find the relevant information is equally burdensome for the payer organization. The collaborators in this case study automated the process, leading to increased efficiency and more accurate quality and risk adjustment submissions.

Collaboration 19: Improving Patient Access to Medication by Automating Prior Authorization Process

Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: CenterX

Executive Summary: The lack of an efficient, standardized process for submitting prior authorization requests for medications was creating administrative burden for the provider and payer organizations in this case study and in some cases delaying patient access to prescribed medications. The collaborators worked with their technology partner to automate data sharing, increase provider visibility into medication coverage, and standardize the submission process for prior authorization. The changes have reduced the workload for the payer and provider organizations and enabled patients to more quickly access their medications.

Collaboration 20: Leveraging Physician-Led VBC Model to Deliver Lower Costs and High-Quality Care

Healthcare organization: CardioVascular Care Providers
Payer organization: Anonymous
Technology partner: Cedar Gate Technologies

Executive Summary: Inpatient treatment for high-risk cardiovascular patients comes with a significant cost for patients, providers, and payers. Costs are lower and outcomes are better when the care for these patients is effectively managed outside the hospital. To achieve this, the collaborators in this case study combined payer and provider data to better predict costs and patient outcomes and then established a bundled payment contract that reduces the costs of caring for patients with high-risk cardiovascular diseases while ensuring they receive the care appropriate for their condition. Outcomes include reduced hospitalization and lower costs.

Collaboration 21: Improving Patient Outcomes and Coding Accuracy by Incentivizing Non-Provider Staff

Healthcare organization: Baptist Health’s Arkansas Health Group
Healthcare organization: MANA (Medical Associates of Northwest Arkansas)
Healthcare organization: UAMS (University of Arkansas for Medical Sciences)
Healthcare organization: St. Bernards Healthcare
Healthcare organization: Washington Regional Medical Systems
Payer organization: Arkansas Blue Cross and Blue Shield
Technology partner: Stellar Health

Executive Summary: The collaborators in this case study noted that some patient populations were completing preventive annual health assessments at lower levels than other populations. To address this disparity and help clinics close care gaps at the point of care, the collaborators implemented a program aimed at incentivizing frontline staff and physicians on a monthly basis for time spent addressing open care gaps. As a result of the program, the participants have seen improved gap closure, improved performance in quality measures, improved coding accuracy, and higher staff morale and engagement.

Collaboration 22: Improving Payer Access to Timely, Accurate Patient-Encounter Data

Healthcare organization: Desert Oasis Healthcare
Payer organization: Health Net
Technology partner: FinThrive

Executive Summary: Lack of access to timely patient-encounter data can prevent payer organizations from being able to identify and close care gaps and accurately report to regulators. The stakeholders in this collaboration partnered to improve payer access by automating the sending of encounter data on a daily basis. The outcomes include reduced workloads, improved patient care, and improved accuracy of regulatory submissions.

Collaboration 23: Improving Equity in Healthcare Access through Improved Data Exchange

Healthcare organization: Harmony Healthcare Long Island
Healthcare organization: Anonymous
Network partner: Community Health Care Association of New York State
Payer organization: Healthfirst
Technology partner: Azara Healthcare

Executive Summary: Poor interoperability between payers and providers negatively impacts many areas, including care quality, administrative workload, and documentation for regulatory requirements. With a shared goal of improving care for all patients, the collaborators in this case study worked together to automate the data exchange process and make it easier for providers to identify and close care gaps. This improved interoperability has increased preventive care, improved quality measure performance, and enabled providers to better address patient needs at the point of care.

Collaboration 24: Simplifying the Prior Authorization Process through Automation

Healthcare organization: Anonymous
Payer organization: Blue Cross and Blue Shield of Minnesota
Technology partner: Availity
Technology partner: Itiliti Health

Executive Summary:  Manual prior authorization workflows are time consuming and costly for payer and provider organizations and can delay patient access to care. To increase provider visibility into which services require prior authorization and to bring automation to the submission and decision processes, the collaborators in this case study worked together to develop a more automated, self-service solution that allows providers to determine whether a given service requires prior authorization, submit a request, and receive a determination, all within their EMR workflow. The technology has improved efficiency, reduced denials, and increased revenue.

Collaboration 25: Streamlining Prior Authorizations for Cardiovascular Patients via a Utilization Management Portal

Healthcare organization: Karing Hearts Cardiology
Payer organization: Humana
Technology partner: Cohere Health

Executive Summary: Diagnosing patients that present with cardiovascular symptoms can be a lengthy process, involving multiple providers and progressive testing that may end up being duplicative or unnecessary. This process is costly and delays patient access to treatment. To address these issues, the collaborators in this case study adopted a utilization management portal that helps providers identify the correct evidence-based care paths and streamlines the prior authorization process for cardiovascular testing and treatments. Achieved outcomes include fewer denials, fewer peer-to-peer reviews, and decreased turnaround times for authorization decisions.

Collaborations Slated for Publication in 2024

The following collaborations were presented at the 2023 K2 Collaborative Summit but full case studies on the partnerships have not yet been published by KLAS or reviewed by the KLAS advisory board. The case studies will be published in KLAS’ 2024 Points of Light report.

Collaboration 26: Using Iterative User Experience Curation to Close Care Gaps and Improve Patient Coding

Healthcare organization: Butler Health System
Payer organization: Highmark
Contract entity: Bridges Health Partners
Technology partner: Holon Solutions

Executive Summary: Identifying and closing patient care gaps and improving the capture and accuracy of diagnosis coding at the point of care for value-based care contracts is imperative for improved patient care and reducing practice burden. Using a provider advocate to inform the user experience and develop more efficient processes, providers and care teams saved time on accessing individual payer portals to close care gaps and improve their diagnosis coding. Regular strategic meetings and clinical team training sessions were conducted to improve workflows and help provider staff adapt to new processes and culture changes.

Collaboration 27: Automating the Exchange of Prior Authorization Information in an Integrated, Machine-First, Real-Time Way

Healthcare organization: Advocate Aurora
Payer organization: UHC/Optum
Technology partner: Rhyme

Executive Summary: Rhyme uses an approach to solve prior authorization called LiveAuth—a platform that stitches providers and payers into a single, seamless workflow with intentionally touchless authorizations between all participants. Rhyme’s LiveAuth GPA measures provider satisfaction and gives payers and providers a common understanding of progress in eliminating abrasion.

Summit Attendees