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K2 Collaborative Summit 2024
Improving Healthcare Efficiency by Encouraging Shared Payer/Provider Goals
Author
Boyd Stewart
Author
Aurene Wilford
With the aim of facilitating collaboration between payer organizations, healthcare delivery organizations, and technology partners, KLAS hosted the fourth annual K2 Collaborative Payer/Provider Summit in May 2024. Representing 96 different payer, provider, and vendor organizations, the 136 individuals in attendance demonstrated their willingness to connect and engage, improve understanding, and partner to bring to light new ways of solving problems. While such collaboration can be difficult to achieve, KLAS has seen these partnerships yield outcomes that are meaningful to all parties.
The summit had three key objectives (click the links to jump to each section’s insights):
- Identify the current state: Understand perceptions on value-based care, identify areas of payer/provider IT alignment, and explore IT spend and priorities for the coming year. Understand regulations and developments in the US digital healthcare infrastructure, such as TEFCA, that have the potential to improve payer and provider efficiency.
- Encourage mutual understanding and shared goals: Trust is crucial for successful payer/provider collaboration. The summit encouraged payer and provider organizations to engage in group discussions and networking opportunities to accelerate mutual understanding and foster partnerships. Discussion topics included value-based care, prior authorizations, payer AI and data analytics, and patient/member engagement.
- Highlight Points of Light Award recipients: Presentations from Points of Light award recipients highlighted successful payer/provider collaborations and their associated outcomes.
The Current State: Understanding Perceptions and Aligning Priorities
Findings drawn from the following three sources helped attendees better understand the current state of the healthcare market and identify areas where payers, providers, and vendors could be better aligned:
- Pre-summit survey to gather attendees’ thoughts on value-based care
- Keynote address by Micky Tripathi, head of the ONC, regarding digital infrastructure developments that have impacted payer/provider data sharing and interoperability
- KLAS research that examined payer and provider areas of alignment in IT spend and priorities, including the most pressing issues payer and provider organizations are trying to solve
Pre-Summit Survey: Perceptions of Value-Based Care Have Shifted over the Last Five Years
As in years past, KLAS asked summit attendees to complete a pre-summit questionnaire. Participants were asked about the following issues regarding the healthcare industry’s shift to value-based care (VBC):
Key insights from the data:
- Distrust between parties in VBC models is growing, even though all parties cite VBC as the preferred environment for payer/provider collaboration: Since 2022, perceptions of trust across all attendee types (payers, providers, and vendors) has steadily declined. Key triggers include churn and friction between payer and provider organizations as both try to accommodate the increased data sharing and visibility required by new CMS regulations. As payers continue to struggle with competition and provider organizations struggle with dwindling margins, the requests for more engagement and data sharing are putting stress on the trust already established. Additionally, the increased focus on consumerism in healthcare has heightened the emphasis on patient/member engagement and requires additional effort, partnership, and alignment between payer and provider organizations.
“The biggest need is building trust.” —Summit attendee from a payer organization
- Most attendees agree that VBC will be the main financial and care-delivery model in 10 years, yet they acknowledge that it comes with many potential challenges: Complex VBC contracts require a heavy administrative and operational lift for both payer and provider organizations. Both parties must assume a level of financial risk and be willing to transparently share data. Further, to improve quality measures, both parties must continually review and analyze data, monitor and test performance and interventions, and link outreach efforts to practice management (e.g., follow-up care and visits).
- Provider organization attendees increasingly identify IT vendors as playing a crucial role in enhancing payer/provider alignment: 81% of provider organization attendees are looking to technology partners to help improve their alignment with payers. This represents an increase of 22 percentage points since last year. Building the payer and provider alignment needed for successful VBC engagement and care delivery requires close collaboration with vendor partners. In some of the collaborations highlighted by this year’s Points of Light awards, organizations were able to partner with vendors to leverage AI, improve processes, and use integrated networks or APPs to improve patient/member engagement.
“We need aligned decisions across market participants. . . . Everyone in the industry must behave like they are part of something bigger.“ —Summit attendee from payer organization
Summit Keynote Address: Call to Action from Micky Tripathi to Participate in TEFCA Exchange
The keynote address at this year’s summit was delivered by Micky Tripathi, National Coordinator for Health Information Technology. In his address, Dr. Tripathi updated summit attendees on the federal government’s healthcare IT strategy to improve interoperability and data sharing—and thus patient care—by encouraging payer and provider organizations to adopt FHIR APIs. In his remarks, he shed light on developments in the digital infrastructure that have impacted payer/provider data sharing and interoperability and issued a call to action for payer and provider organizations to participate in TEFCA exchange for 2024.
Documentation quality and content varies significantly across provider organizations, and likewise, internal processes and workflows vary across payer organizations. FHIR APIs are facilitating nationwide governance of health information exchange, attempting to bridge the gap between payer and provider interoperability and promote information exchange and transparency. Enforcing information-blocking rules and ensuring responsible use of digital information will help with data sharing. However, interoperability is not scalable without a network infrastructure for FHIR APIs. TEFCA was identified as the needed infrastructure to provide scalability and simplify health data exchange. With TEFCA, organizations can avoid negotiating the same issues related to data use, security, onboarding, etc., with each payer or provider partner. TEFCA is also the policy and technical approach to connecting networks (Qualified Health Information Network [QHINs], HIEs, etc.). At the Summit, Dr. Tripathi invited 10 payer and 10 provider attendees to volunteer for payer/provider TEFCA exchange in 2024 using QHINs and FHIR-based APIs. These partnerships will need to be able to demonstrate payload exchange to support care management and coordination as well as demonstrate feasibility of and build trusting partnerships for improved healthcare operations.
IT Alignment: Payer & Provider Organizations Aligned in Their Desire to Improve Data Aggregation, Patient/Member Engagement, and the Claims Process
As payer and provider organizations collaborate to resolve issues, it is important for each to know the other’s current IT priorities. At the summit, KLAS shared research gathered in 2024 that examined payer and provider alignment in IT spending and priorities, including the most pressing issues payer and provider organizations are trying to solve.
In the wake of COVID-19, payer and provider organizations are both looking to balance newly learned agility in IT adoption with sustainable efforts and governance. Both are hungry to experiment with new technology, gain accessible and accurate data, and better accommodate patient preferences to improve patient/member engagement. Further, provider organizations are putting increased focus on improving employee burnout and well-being. Payers are also adjusting the way they partner with the provider community to control costs while building provider trust and adapting to member needs.
IT continues to be a top strategic priority for payer and provider organizations, with both planning to increase IT spending. However, new technology is more often a driver of IT spending for provider organizations than for payers. Regardless, both are mutually aligned around the desire to (1) aggregate complete and accurate data to make more informed care decisions, (2) improve member and patient engagement across the care continuum, and (3) improve claims processes.
Overall, while both parties view AI as a path to achieve outcomes, adoption at an enterprise level is happening slower than many anticipated.
Mutual Understanding & Shared Goals: How Payer & Provider Organizations Can Improve Collaboration in Key Areas
KLAS had subject matter experts lead breakout discussions in four key areas identified by the K2 Collaborative Steering Committee as areas in which payer/provider alignment is imperative: (1) value-based care payment models, (2) prior authorizations, (3) payer AI and data analytics, and (4) patient/member engagement.
Shifting to Value-Based Care
Payer and provider attendees were aligned on prioritizing the integration of social determinants of health (SDOH) into their strategic plans for improving patient care (see chart to the right). There is an overall consensus that having efficient, transparent data sharing and trusting partnerships is also essential for shifting to VBC models as it creates a win-win scenario for both parties.
Conference attendees agreed that VBC contracts are complex and that there is associated tension between payer and provider organizations on how to best manage these contracts to provide optimal care. Provider attendees reported struggling with a lack of standardization across payer contracts that focus on different targets and metrics. They feel VBC contracts are successful when payers have taken on meaningful downside risk and partner with them in a meaningful way that impacts ROI.
Some payer attendees reported favoring VBC contracts over fee-for-service arrangements because of VBC’s potential to improve member care. VBC contracts enable patients to be cared for in a way that is appropriate for their level of acuity. Costs are more predictable with VBC models, and there are notable reductions in ED visits.
Conference attendees were asked what each party can do to more effectively partner and participate in VBC models. Their responses are summarized below:
What Can Payer Organizations Do to Contribute to Effective VBC Contracts?
- Simplify or standardize processes across payer organizations: Provider organizations currently face multiple requirements to log in to payer portals, increasing their administrative burden.
- Share timely patient data: Provider organizations can deliver better care when they have access to timely, detailed patient data, including detailed financial information. This data needs to be shared at the member level and in a format that allows provider organizations to ingest and analyze it.
- Provide a deep view of payer adjudication policies
- Understand the cost structure of providing quality care: Payer organizations also need to ensure their requests for meaningful reporting do not overburden provider organizations that are already strapped for resources.
- Provide financial support through more reasonable targets and other quality bonus incentives
What Can Provider Organizations Do to Contribute to Effective VBC Contracts?
- Review performance, test interventions, and modify processes: Provider organizations that are actively engaged in these things are better partners. This may include correcting billing errors and integrating EHR systems with data collection for accurate performance measurement. Linking outreach efforts to practice management (e.g., setting up appointments and following up on missed visits) is critical to quality performance improvement.
- Take on some of the risk: Payer organizations appreciate when provider partners are willing to take on some of the risk in VBC contracts and be transparent in sharing data.
- Provide access to detailed clinical data: Payer organizations can better support provider organizations when they have access to detailed clinical data for their members. This includes access to population health data as well as unstructured and structured data (e.g., notes from care coordinators, pharmacist records, and social worker entries).
- Be nimble in adopting new technology: Some provider organizations are slow to adopt new technologies that would help them better manage VBC contracts.
Improving the Prior Authorization Process
The process of obtaining prior authorization is a significant barrier to patient care. This was discussed in detail at the conference during breakout discussions and during the Points of Light presentations. Attendees unanimously agreed that automating and improving efficiency in this area is a major industry challenge. Many IT vendors are investing in and developing solutions to improve the efficiency of the prior authorization process, and many payer and provider organizations are willing to align and partner together to reduce the administrative and financial burden. However, despite this agreement, 60% of payer attendees and over 75% of provider attendees report that they have seen little to no improvement over the last year in the prior authorization experience. Some even feel the experience has deteriorated.
These attendees report that progress is incremental but slow, with provider organizations underestimating the lift associated with automating prior authorizations. Additionally, organizations have found it difficult to improve efficiency for specialty areas in which multifactor authorization is required. Others report an increased volume of prior authorization requests since COVID-19. This added volume exacerbates the administrative burden for both sides. Increased commitment to and adoption of FHIR APIs and standard implementation guides across payer and provider organizations has the potential to improve interoperability and alleviate this prior authorization burden.
What Can Payer Organizations Do to Improve Prior Authorization Efficiency?
- Provide timely access to prior authorization data: Provider organizations are requesting more timely access to the status of prior authorization requests and approvals that would allow providers to see patient benefit detail at the point of care and effectively communicate expectations to patients.
- Partner to provide electronic process: Though some provider organizations have piloted electronic prior authorizations, they are struggling to find payer partners willing to also leverage these processes.
- Be flexible with coding changes: Provider organizations would like payers to be more flexible with coding changes and trust their clinical decision-making. Provider organizations would like payers to be open to review and revisit some medical necessity claims once they have been rejected.
“The Da Vinci standard (CRD, DTR, PAS) and regulations are promising, but we need payer-agnostic tools that can deliver an end-to-end experience, and payers still need to build out the technology to automatically adjudicate policy decisions.” —Summit attendee from provider organization
What Can Provider Organizations Do to Improve Prior Authorization Efficiency?
- Understand the rules and policies payers must adhere to: Provider organizations that understand the rules and policies payers must adhere to are better partners in navigating the prior authorization landscape. Having a deep understanding of health data standards, terminology, and policies is essential. Misinterpreted data can hinder information exchange, so it is vital that all implementation teams are educated on these standards.
- Build partnerships of trust: Payers report the need for partnerships of trust that include transparent communication and alignment on objectives and outcomes. When something isn’t right, discussing the issue early on will foster a greater level of trust.
- Bring the right people to the table: Provider organizations need to ensure the right people from their organization are involved in discussions so that efforts to streamline processes are properly supported. The technical integration required for prior authorizations is complex, so having strong governance structures is imperative.
- Provide timely data sharing: Some payers still have only limited access to patient data and struggle with receiving timely PA documentation from provider organizations. This delays approval and negatively impacts turnaround times for care.
Utilizing Payer AI & Data Analytics
AI has the potential to reshape healthcare delivery, improve patient outcomes, and drive operational efficiencies. However, conference attendees had mixed perceptions of the technology. While a large portion was cautiously optimistic about embracing it, many attendees expressed valid concerns over data governance and protecting the privacy and security of patient data. The general consensus among provider attendees was that they trust their EHR vendors and other IT partners with whom they have longstanding relationships to navigate this territory.
One-third of payer attendees use predictive AI/machine-learning algorithms to identify which prior authorization requests have a high probability of being approved without manual review, detect claims errors before finalization, and enable population health teams to manage patients. The few payer organizations that are using generative AI are experimenting with agent-assist models and quality checks on member correspondence. Some are using ambient listening for call centers and care management; others are piloting generative AI to improve internal efficiencies.
Under half of the provider organizations surveyed are using predictive AI. Those that are use chatbots like ChatGPT and DAX Copilot or use predictive AI in FDA-approved imaging use cases and in revenue cycle use cases to improve accuracy in coding, documentation, denials, and billing. The provider attendees using generative AI are using ambient speech and generative AI for mailbox management. Some are piloting it for clinical documentation and coding, while others use it in claims statusing (medical record procurement).
What Should Payer & Provider Organizations Take into Account When Considering AI?
- Have a strategic focus on data: Machine learning is only as good as the quality of the data informing it. Payers and providers should evaluate the availability of clean, structured data and their ability to use unstructured data. They should also evaluate their data integration capabilities and data privacy and security measures. High-quality, comprehensive data is crucial for the effective functioning of AI technologies.
- Ensure the technology complies with healthcare regulations: Any technology needs to comply with healthcare regulations and have an ROI that benefits both parties.
- Encourage internal sponsorship: For an AI program to be successful, stakeholders should gain sponsorship from executives and managers and have the right training programs in place for successful adoption.
- Be agile: Payer and provider organizations should be agile in their approach to partnership and be willing to pivot when plans aren’t working as anticipated or other needs arise.
- Realize that gaining buy-in takes time and strategic communication: Organizations should emphasize the benefits of the initiative (e.g., time savings, improved quality scores) to overcome initial hesitation. Engage early with key stakeholders—such as security, IT, quality measure, and contracting teams—to ensure comprehensive understanding of the project’s value. Clear points of contact for technical and clinical sides will help facilitate ongoing collaboration.
- Implement robust security measures
- Invest time and capital into change management: Help provider and payer staff understand new processes and improve efficiency.
Engaging Patients/Members in Their Care Journey
Consumerism is increasingly prevalent in healthcare. Patient engagement has been at the forefront of provider organizations’ strategic goals for years, and payer organizations are also increasing their focus on member engagement—100% of payer attendees agreed that engaging members in the care journey is an area of significant investment, as doing so can reduce costs for members, health plans, and provider organizations. The collaborations highlighted by the 2024 Points of Light awards showcase a variety of ways in which payer organizations have engaged their members. For example, one payer integrated patient insights directly into pharmacy systems, enabling positive member interactions, improving refill outreach, and increasing members’ understanding of their benefits. Other organizations have driven member engagement through home health outreach, which 61% of payer summit attendees said is a strategic priority. Further, a few attendees said they are turning to predictive AI technology.
With so many technologies in the healthcare space, summit attendees were asked to list technologies that they feel can improve the patient/member experience as well as relieve the administrative burden for provider organizations. The most commonly mentioned technologies include:
- Ambient speech technology
- Appointment reminders
- Patient education (e.g., information to encourage medication adherence)
- Pre-appointment registration (e.g., health history)
- Prescription reminders
- Self-scheduling
What Can Payer & Provider Organizations Do to Build Trust with Each Other?
As payer organizations invest in IT solutions to improve the member experience and encourage member engagement, they need provider organizations to fully adopt these solutions as well so that the desired outcomes can be achieved. When both payer and provider organizations have a problem-solving mindset and align with each other on common goals, both will achieve greater success with improving patient/member engagement. To encourage trust, organizations can do the following:
- Be open and honest in their communication with each other
- Align on common goals and measures of success
- Submit accurate, complete data and share historical patient data and claims/financial data
- Set appropriate leadership expectations
- Be accountable and agile
- Provide access to payer data directly in the provider’s portal
“There needs to be fair dialogue and clear expectations between payers and providers.” —Summit attendee from provider organization
Next Steps for KLAS
Both payer and provider organizations recognize the need for improved collaboration and partnership. KLAS’ goal is to facilitate more connections between these organizations, helping them better engage with and understand each other and creating a stronger foundation from which to tackle tough challenges together. KLAS will work toward this goal in the following ways:
- Encourage and facilitate partnerships: KLAS will continue to work closely with interested payer and provider organizations to help build collaborative relationships that drive change, supported by KLAS’ actionable insights. Our engagements with organizations include follow-up meetings to reduce payer/provider friction and hold both sides accountable to agreed-upon actions. To participate in an engagement, contact KLAS at K2@klasresearch.com.
- Highlight opportunities for alignment and collaboration: As a third party, KLAS can impartially gather data and perspectives from payer and provider organizations to (1) identify areas where they have opportunities to align their strategic plans and road maps and (2) highlight points of friction where collaboration can be improved. Our ongoing research provides direction for payer and provider organizations interested in solving key issues in the healthcare industry. KLAS will continue to share our findings in future reports and summits.
- Facilitate payer/provider forums: Held on a bimonthly basis, KLAS’ K2 Collaborative forums enable payer and provider organizations to discuss relevant issues, share insights and successes, identify opportunities for partnership, and brainstorm ways to overcome challenges.
- Continue to recognize Points of Light: KLAS will continue to highlight “points of light,” or collaborations in which provider organizations, payer organizations, and healthcare IT vendors have found success through collaborative partnerships. When determining which partnerships should receive a Points of Light award, we consider impact on the patient, payer, and provider experience as well as innovation, creativity, scalability, and replicability. To share your collaboration story, please reach out to Aurene Wilford (aurene.wilford@klasresearch.com) or Boyd Stewart (boyd.stewart@klasresearch.com).
Details on 2024 Points of Light Recognition
As part of the K2 Collaborative, KLAS celebrates successful collaborations between payer and provider organizations and HIT vendors through the annual Points of Light awards. In 2024, KLAS recognized 22 such collaborations. At the K2 Collaborative Summit, all collaborators were given the opportunity to present an overview of their project and achieved outcomes. To highlight the collaborations with the greatest positive impact, summit attendees selected four 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 2024 report for in-depth case studies of each collaboration.
Peak Award Recipients
Collaboration 7: Closing Care Gaps for HEDIS Measures through Natural Language Processing
Healthcare organization: Prospect Medical Holdings
Payer organization: AmeriHealth Caritas
Technology partner: Astrata & ELLKAY
Executive summary: Accurate data is needed for HEDIS reporting, but claims data does not always provide payers and providers with a complete picture of patient/member compliance with Medicaid measures. To mitigate this challenge, the stakeholders in this collaboration created a continuous HEDIS review workflow to triage cases and close care gaps.
Outcomes: Increased efficiency in identifying care gaps, better population health management, and increased financial return from quality measures for AmeriHealth Caritas. Reduced redocumentation efforts for Prospect Medical Holdings as well as reduced number of care gaps that needed manual review. Comprehensive member follow-up on care gaps.
Collaboration 15: Reducing Administrative Burden & Time to Care by Automating Prior Authorization for Inpatient Stays
Healthcare organization: Henry Ford Health System
Payer organization: Anonymous
Technology partner: Rhyme
Executive summary: For the provider organization in this collaboration, the process of gaining prior authorization for inpatient stays was labor and time intensive. Additionally, the payer organization often had to deal with incomplete submissions. To address these challenges, the stakeholders worked with Rhyme to streamline the prior authorization process through automatic data sharing.
Outcomes: Provider time savings (Automatic submission of administrative data has saved 4 minutes per case or 200 minutes per week, and automatic status updates have saved an additional 2 minutes per case or 100 minutes per week). Rhyme AuthScore increased from less than 1.0 to 2.8 through automation of case submissions. Henry Ford Health System’s decisions rendered via electronic workflows increased from 33% to 94%. 45% reduction for Henry Ford Health System in prior authorization turnaround time compared to pre-automation baseline.
Collaboration 18: Automating Prior Authorizations through Networked FHIR Connections
Healthcare organization: UC Davis Health
Payer organization: Regence
Technology partner: eHealth Exchange
Executive summary: Payer and provider organizations need to be able to effectively and efficiently share data throughout the prior authorization approval process, but the complexities of data sharing often create an administrative burden and high costs for organizations. In this collaboration, UC Davis Health and Regence partnered with eHealth Exchange to facilitate faster, easier data sharing through FHIR technology.
Outcomes: Networked FHIR connections that enable QHINs to facilitate transaction requests between payer and provider organizations.
Collaboration 22: Transforming Medicare & Medicaid Member Engagement through AI-Powered SDOH Risk Prediction & Personalization
Healthcare organization: Sentara Health System
Payer organization: Sentara Health Plans
Technology partner: N1 Health
Executive summary: Negative social determinants of health (SDOH), such as unsafe housing and food insecurity, can worsen patient health and lead to them overusing the emergency department (ED). In this collaboration, Sentara Health System engaged N1 Health to identify SDOH for Medicare and Medicaid members and match these individuals with benefits to facilitate better care and program re-enrollment. The partners also used AI to determine which patients had high risk for housing insecurity so that they could provide housing assistance via a grant-funded program.
Outcomes: 6% increase in member retention. Reduced number of ED readmissions for members enrolled in housing-assistance program. Increased rate of re-enrollment for Medicaid members who previously were at high risk of being unenrolled. Improved rates for annual wellness and well-child visits through AI personalization.
2024 Points of Light Recognition
Summaries of the 2024 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: Improving Prior Authorization Efficiency through Automated, Touchless Data Exchange
Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: Rhyme
Executive summary: The prior authorization process for the provider and payer organizations in this case study was inefficient and manual due to a lack of integration between the organizations’ data, delaying patient access to advanced imaging services. The collaborators worked with their vendor partner, Rhyme, to connect the provider and payer workflows and share prior authorization data in real time. This automated process has minimized the need for manual touches and decreased the turnaround time for prior authorization approval, enabling patients to more quickly receive needed services.
Collaboration 2: Empowering Community Pharmacists to Contribute to Value-Based Care through App & Incentive Program
Healthcare organization: Independent community pharmacies†
Payer organization: Healthfirst
Technology partner: Hyphen & PrimeRx/Micro Merchant Systems
† This group is comprised of 250 independent community pharmacies that are not formally affiliated with each other.
Executive summary: In New York, 80% of Medicare Advantage (MA) members visit their community pharmacy 5–10 times a year, which is more than they visit their primary care physician. Delivering patient insights directly to pharmacy systems can better facilitate positive interactions with patients/members, reduce friction between payer and provider organizations, improve refill outreach, and increase patients’ understanding of their benefits. The vendor and payer organization in this collaboration worked together with local pharmacies to create a solution that connected disparate data and identified care gaps. This solution led to better patient outcomes, greater financial viability for the pharmacies, and improved CAHPS scores.
Collaboration 3: Reducing Costs & Adverse Patient Events by Closing Gaps in Transitions of Care
Healthcare organization: Anonymous
Payer organization: Humana
Technology partner: PointClickCare
Executive summary: During transitions of care, payer and provider organizations have to manage several moving parts; if clinical data is lost or patient care coordination goes awry, it can negatively impact patient outcomes and the cost of care. In this collaboration, the stakeholders worked together to create a solution that identifies when care transitions are occurring and provides care teams with appropriate clinical information, allowing them to close care gaps.
Collaboration 4: Improving Quality Metrics & Outcomes for Medicare Advantage Patients through Real-Time Information
Healthcare organization: Privia Health
Payer organization: Humana
Technology partner: Bamboo Health
Executive summary: Lack of timely data can prevent provider organizations from facilitating appropriate care coordination after patients are discharged from a hospital visit. The payer and provider organizations in this collaboration worked together with Bamboo Health to increase visibility into Medicare Advantage (MA) patient data and improve CMS Star Ratings. The outcomes include improved performance with CMS measures, timelier follow-up, and better care coordination.
Collaboration 5: Automating Release of Information to Support Quality Improvements
Healthcare organization: Anonymous
Payer organization: AmeriHealth Caritas
Technology partner: Moxe Health
Executive summary: Payer organizations need timely access to accurate clinical data; however, the release of information process can often be cumbersome for provider organizations, causing them to be overwhelmed by payer requests. The stakeholders in this collaboration implemented technology to automate the chart-retrieval process, leading to improved data access for the payer organization and a reduced administrative burden for the provider organizations.
Collaboration 6: Using API Technology to Automate Managed Care Referral Authorizations
Healthcare organization: Anonymous
Payer organization: UnitedHealthcare
Technology partner: Waystar
Executive summary: Authorizing managed care referrals can be a labor-intensive, time-consuming process that burdens provider organizations, health plans, and patients. In this collaboration, the stakeholders worked to combine API technology with robotic process automation to streamline the referral process and provide transparency into the status of referrals. Outcomes include reduced administrative burdens and increased access to care for patients.
Collaboration 7: Closing Care Gaps for HEDIS Measures through Natural Language Processing
Healthcare organization: Prospect Medical Holdings
Payer organization: AmeriHealth Caritas
Technology partner: Astrata & ELLKAY
Executive summary: Accurate data is needed for HEDIS reporting, but claims data does not always provide payer and provider organizations with a complete picture of patient/member compliance with Medicaid measures. To mitigate this challenge, the stakeholders in this collaboration created a continuous HEDIS review workflow to triage cases and close care gaps. Outcomes include increased efficiency in identifying care gaps, fewer cases that need to be manually reviewed, and better patient/member care.
Collaboration 8: Streamlining Prior Authorization through Comprehensive, Real-Time Data Exchange
Note: This case study was created in conjunction with KLAS’ K2 Collaborative and presented at the 2024 summit.
Healthcare organization: Anonymous
Payer organization: Highmark Inc.
Technology partner: enGen
Note: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross Blue Shield Association. Highmark offers Blue Cross and Blue Shield products/services in 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania.
Executive summary: The prior authorization process often causes friction between payer and provider organizations due to back-and-forth requests for data. In this case study, enGen worked with the collaborating payer and provider organizations to create a solution for utilization, case, and disease management, thus facilitating better data transparency. Use of this solution led to better turnaround times for prior authorizations and reduced manual tasks.
Collaboration 9: Reducing Administrative Burden by Resolving Overpayment Claims via a Third-Party Partner
Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: TREND Health Partners
Executive summary: The payer and provider organizations in this collaboration were struggling with a high volume of correspondence regarding potential overpayment claims, creating an administrative and time burden for both organizations. To resolve this issue, they partnered with TREND Health Partners to review potential overpayments and facilitate communication between the organizations. Outcomes include a reduced administrative burden for the organizations and improved financial performance for the health plan.
Collaboration 10: Reducing Administrative Burden & Improving Patient Outcomes through Bundled Prior Authorization Approvals
Healthcare organization: OrthoTennessee
Payer organization: Humana
Technology partner: Cohere
Executive summary: A lengthy prior authorization process was delaying needed care for OrthoTennessee patients who had received knee surgery. To resolve this issue, they partnered with Humana and Cohere to bundle prior authorizations together into a single transaction. This reduced the administrative burden on the provider and payer organizations and increased the timeliness of patient care.
Collaboration 11: Using EOB Data to Create Complete Clinical Profiles & Close Care Gaps during In-Home Wellness Assessments
Healthcare organization: Signify Health
Payer organization: Humana
Executive summary: Socioeconomic factors, from food insecurity to lacking health literacy, can prevent health plan members from being involved in their health and lower the quality of their health outcomes. Additionally, payer and provider organizations are unable to fully care for and support members when they are unaware of the factors impacting members’ wellness. The payer and provider organizations in this collaboration worked together to create data transparency for clinicians, thus improving member engagement and health outcomes as well as compliance with HEDIS measures.
Collaboration 12: Using Data-Driven Process Improvement Initiatives to Improve Efficiency & Close Care Gaps for Preventive Screenings
Healthcare organization: General Practice Associates
Payer organization: Cigna Healthcare
Technology partner: CareAllies
Executive summary: Preventive screenings for breast cancer, colorectal cancer, and diabetic retinopathy are vital to improving patient health outcomes and reducing costs for payer and provider organizations. Many patients of the provider organization in this study were not receiving or following through with referrals for these necessary preventive screenings, so the provider and payer organizations collaborated with CareAllies to create a better referral workflow. Outcomes include an increased number of referrals, improved patient engagement, and improved Star Ratings.
Collaboration 13: Improving the Completeness & Accuracy of Risk Scores for Medicare Advantage Patients through Clinical Data Sharing
Healthcare organization: Anonymous
Payer organization: Anonymous
Technology partner: Epic & Optum
Executive summary: When Medicare Advantage patients are seen by provider organizations other than their primary care physician (PCP), they may receive diagnoses that their PCP is unaware of. This lack of data transparency can negatively affect patient care, risk adjustment scores, and CMS reimbursements. The payer and provider organizations in this collaboration worked together with Epic to improve patient care and risk adjustment scores through data transparency at the point of care.
Collaboration 14: Easing Administrative & Operational Burdens through Electronic Prior Authorization
Healthcare organization: MultiCare
Payer organization: UnitedHealthcare
Technology partner: Epic, Optum & Rhyme
Executive summary: The complex nature of prior authorizations often delays needed patient care and creates a large administration burden for payer and provider organizations. To mitigate these issues, the stakeholders in this collaboration worked to create an electronic prior authorization process via Epic Payer Platform to automate prior authorization requests, reducing the burden on payer and provider staff and improving patient access to care.
Collaboration 15: Reducing Administrative Burden & Time to Care by Automating Prior Authorization for Inpatient Stays
Healthcare organization: Henry Ford Health System
Payer organization: Anonymous
Technology partner: Rhyme
Executive summary: For Henry Ford Health System, the process of gaining prior authorization for inpatient stays was labor and time intensive. Additionally, the payer organization often had to deal with incomplete submissions. To address these challenges, the stakeholders worked with Rhyme to streamline the prior authorization process through automatic data sharing. Targeted outcomes include faster decision rates and turnaround times for prior authorizations and a reduced administrative burden for the payer and provider organizations
Collaboration 16: Using FHIR Standards to Streamline Prior Authorization Management & Improve Patient Care
Healthcare organization: Harmony Park Family Medicine
Payer organization: Humana
Technology partner: athenahealth & Availity
Executive summary: The manual nature of prior authorizations creates an administrative burden for provider and payer organizations and delays patient access to care. The stakeholders in this collaboration worked to automate the prior authorization process by using Availity to connect the payer and provider solutions, allowing data to be exchanged more seamlessly. This project led to a faster turnaround time for prior authorization approvals, a reduced administrative burden, and improved access to care for patients.
Collaboration 17: Streamlining Release of Information through Automated Requests
Healthcare organization: Riverside Health
Payer organization: Humana
Technology partner: Epic
Executive summary: The manual efforts required for release of information requests created a large administrative burden for the stakeholders in this collaboration. In an effort to reduce this burden, the stakeholders worked with Epic to bundle and automate requests for clinical data. This collaboration led to faster turnaround times for release of information, a reduction in administrative work, and increased provider satisfaction.
Collaboration 18: Automating Prior Authorizations through Networked FHIR Connections
Healthcare organization: UC Davis Health
Payer organization: Regence
Technology partner: eHealth Exchange
Executive summary: Payer and provider organizations need to be able to effectively and efficiently share data throughout the prior authorization approval process, but the complexities of data sharing often create an administrative burden and high costs for organizations. In this collaboration, UC Davis Health and Regence partnered with eHealth Exchange to facilitate faster, easier data sharing through FHIR technology. The stakeholders aim to process prior authorizations more quickly via a single data exchange workflow that connects the provider organization with all payer organizations.
Collaboration 19: Expanding Care Management for Rising-Risk Populations through Deviceless RPM
Healthcare organization: Carle Health
Payer organization: Anonymous
Technology partner: Lightbeam Health Solutions
Executive summary: Provider and payer organizations typically have the tools and data needed to identify and provide care management to high-risk patient populations. However, patients with rising risk are harder to identify and provide care to. To improve care management for this group, the stakeholders in this collaboration implemented Lightbeam Health Solutions’ deviceless remote patient monitoring solution. This solution has led to improved health outcomes for high- and rising-risk patients as well as improved patient engagement.
Collaboration 20: Closing HCC Coding Gaps through an Information Retrieval Assistant
Note: This case study was created in conjunction with KLAS’ K2 Collaborative and presented at the 2024 summit.
Healthcare organization: Independence Health System
Payer organization: Highmark Inc.
Technology partner: Holon Solutions
Note: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross Blue Shield Association. Highmark offers Blue Cross and Blue Shield products/services in 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania.
Executive summary: Hierarchical Condition Category (HCC) coding plays an integral role in assessing patients’ risk scores and contributes to quality patient care and appropriate reimbursements. However, provider organizations don’t always have the needed information or training to be able to accurately complete HCC coding and close coding gaps. The stakeholders in this collaboration worked together to seamlessly transfer payer information into clinician workflows, leading to improved data transparency and, ultimately, more accurate coding.
Collaboration 21: Leveraging AI-Driven Personalization & Virtual PCPs to Modernize Member Engagement & Risk Stratification Accuracy
Payer organization: Cigna Healthcare
Technology partner: N1 Health & MDLIVE
Executive summary: Due to changes in the health plan market, Cigna Healthcare’s membership unexpectedly increased from 350,000 members to 1 million members. In order to ensure appropriate care and reimbursement, the payer organization had to quickly assess, engage, and offer care options to these new members. Cigna worked with MDLIVE and N1 Health to proactively reach out to all members with a help-first approach and schedule annual wellness visits for them, ensuring that the members received the right care and that the payer organization was properly reimbursed.
Collaboration 22: Transforming Medicare & Medicaid Member Engagement through AI-Powered SDOH Risk Prediction & Personalization
Healthcare organization: Sentara Health System
Payer organization: Sentara Health Plans
Technology partner: N1 Health
Executive summary: Negative social and environmental factors, such as unsafe housing or food insecurity, can worsen patient health and lead to them overusing the emergency department (ED). In this collaboration, Sentara Health engaged N1 Health to identify social determinants of health (SDOH) for Medicare and Medicaid members and match these individuals with benefits to facilitate better care and promote re-enrollment. The partners also used AI to determine which patients had high risk for housing insecurity so that they could provide housing assistance via a grant-funded program. These efforts lead to reduced ED usage, increased use of preventive services, and higher re-enrollment in Medicare/Medicaid.
Summit Attendees
Adrienne Mabee, Software Product Manager at enGen/Highmark Inc.
Alan Ford, Director Provider Relations at Cambia Health Solutions
Alan Whittington, Director, Risk Adjustment at Highmark Inc
Amy Mattingly, Director, Product Management at Huma
Andy Allen, VP, Health Services and External Partnerships at BCBSLA
Andy Corts, CTO at OneOncology
Angela Hartsell, Medical Director, Informatics at Cone Health
Angie Krout, VP, Client Delivery at Ensemble Health Partners
Anna Taylor, AVP, Population Health and Value-Based Care at MultiCare Health System
Anthony Magliocco, CEO at Protean BioDiagnostics
Antonio Fonseca, Director, Patient Financial Services (Hospital & Professional) at UCSF Health
Aubree Booth, CSM, National Health Plans at PointClickCare
Beth Zuehlke, Chief Customer Officer at Moxe Health
Bill Banks, VP, Managed Care & Revenue Cycle at St. Elizabeth Healthcare r
Brad Gingerich, VP, Revenue Cycle Operations, Payor Strategy at Ensemble Health Partners
Brian Shelly, Executive Director at athenahealth
Bruce Rogen, CMO at Cleveland Clinic Employee Health Plan & Chair at Cleveland Clinic Quality Alliance CIN
Carisma Baker, Advisory SVCS Consultant at Optum
Caroline Krubsack, Principal Segment Marketing Manager at Surescripts LLC
Carrie Roberts, AVP, Revenue Cycle Applications at Ascension
Cathy Beebe, Director, Managed Care at OSF Healthcare System
Cathy Thompson, Senior Business Product Manager at Roche
Chad Westover, CEO at University of Utah Health Insurance Plans
Charlton Park, CFO at University of Utah Hospitals and Clinics
Chelsea Parris, Assistant Director at Vanderbilt UniversityMedical Center
Chris Cowman, VP, Transformation Strategy at enGen
Chris Jones, VP, Business Development at Astrata
Chris Walker, AVP, Interoperability at Humana
Christine Creel, Strategic Provider Partnership Executive at Florida Blue
Christy Pehanich, AVP at Geisinger
Chuck Feerick, VP, Growth and Sales at Clarify Health
Connie Renda, Professor and Program Director at San Diego Mesa College
Crystal Ewing, VP, Product Management at Waystar
Crystal Strosahle, Program Manager, ACO at ThedaCare
Dan Wilson, CEO and Founder at Moxe Health
Daniel Durand, Chief Clinical Officer at LifeBridge Health
Darryl Britt, CEO at Apprio
Dave Wilcox, Director, HP Systems at University of Utah Health Plans
David Weathington, VP, Network and Provider Success at Elevance Health
Deborah Cooledge, Director, Product at Optum Insights
Dennis Price, Director, Revenue & Operations at UC San Diego Health
Derek De Young, Payer Platform—Research and Development at Epic
Devon Zoller, Associate Medical Director at Cleveland Clinic Employee Health Plan
Diana Sonbay-Benli, Chief Product Officer at TriZetto Products Group at Cognizant
Diane Gabrielsen, Executive Consultant at Health Payer Innovations
Dominic McGinley, Senior Manager, Data Products at Signify Health
Erik Summers, CMO, MD at Wake Forest Baptist Health
Gary Meyer, Strategic Markets Executive at Cognizant
Glen Klink, Strategic Sourcing Consultant Director at Elevance Health
Glenn Raley, Interoperability Product Management Fellow at Humana
Gregory LeGrow, Executive Director, Payer Strategy at athenahealth
GT Sweeney, CIO at Healthfirst
Heather Davidson, Director, HIM, Hospital Coding, and Revenue Integrity at UC San Diego Health
Howard Brill, enior VP, Population Health and Quality at Monroe Plan
Jacob Luria, President & Founder at N1 Health
James Murray, VP, Clinical Informatics and Interoperability at CVS Health
James Whitfill, SVP, Chief Transformation Officer at HonorHealth
Jamie Davis, VP, Revenue Cycle at SSM Health
Jana Danielson, VP, Revenue Cycle at Nebraska Medicine
Jay Nakashima, President at eHealth Exchange
Jed Cusimano, VP, Data Products at Signify Health
Jeff Smith, CEO at Bamboo Health
John Cope, Director, Stars Technology at Humana
Jonathan Zimmerman, CEO at Holon Solutions
Joseph Painter, Global Client Partner at UST
Julie Smith, Manager, Product Management at InterSystems
Justin Williams, Director, Business Solutions at +Oscar
Kali Durgampudi, President & CEO at Apprio
Kalyana Kanaparthy, Executive Director, Physician Advisor Services at AdventHealth Orlando
Karen Ashton, Director, Information Services and Technology at MultiCare Health System
Kathleen Aller, Director, Market Strategy, Healthcare at InterSystems
Katie LeBlanc, VP, Corp Dev & Interim Chief Transformation Officer at Providence
Katrina Fowler, Director, Revenue Cycle Integration at AdventHealth
Kelli Ford, Director, Managed Care at JPS Health Network
Kelly McMullen, Technical Manager at University of Utah Health Plans
Kenny Bramwell, Senior Medical Director at Select Health
Keri Whitehead, System Director, Patient Financial Services at UC San Diego Health
Kerry Gillespie, Executive Consultant at Kerry Gillespie LLC
Kevin Worrall, Implementation Executive at Epic
Kim Pierce, Medical Director, Ambulatory Quality & Population Health at Independence Health System
Kim Spath, Senior Director, Provider Engagement at Geisinger Health Plan
Kiran Malathi Mathur, Senior Data Engineer at Prospect Medical
Kirk Anderson, Chief Technology Officer and VP at Cambia Health Solutions
Kory Hjelm, Director, Provider Integrations at Rhyme
Kristina Essenmacher, Director at Henry Ford Health System
Kristine Bartley, Associate VP, Episodic & Alternative Payment Models at Ascension
Kristy Yohey, VP, Provider Cost Solutions at Highmark Inc.
Kumar Kanisan, Managing Director at Deloitte
Lisa Fallert, COO at University of Utah Health Plans
Mandie Brzon, VP, Revenue Cycle at Ascension
Manish Jaiswal, VP & Head at Newgen Healthcare at Newgen Software
Mark Fleming, Senior Director, Product at Availity
Matt Rohrer, Director, Patient Access at UW Health
Matt Tierney, Market Leader at Florida Blue
Meade Monger, Founder at CenturyGoal
Michael Clark, President & Chief Growth Officer at RAAPID AI
Michael Hinkson, Senior Director at N1 Health
Michael Marchant, Director, Interoperability and Innovation at UC Davis Health
Michael Westover, VP, Data Partnerships and Informatics at Providence
Micky Tripathi, PhD, MPP, National Coordinator for Health IT at HHS-ONC
Miguel Vigo, hief Revenue Cycle Officer at UC San Diego Health
Modak Raj, VP, Digital Health Strategy at UST
Monica Lovelace, VP, Alliances at Azara Healthcare
Nancy Vannest, VP, Payor Contracting, Management & Performance at Parkview Healt
Neil Kulkarni, VP, Customer & Clinician Experience Solutions at Highmark Health
Nick Ridings, SVP, Growth at ClarisHealth
Nicole Sunder, Senior Director, Solution Design at PointClickCare
Patricia Warble, Senior Director, Program Management at Prospect Medical Holdings
Patrick Warren, VP, Sales at Trend Health Partners
Perry Sweet, EVP, Enterprise Client Experience at Waystar
Pete Chang, SVP, Chief Transformation Officer at Tampa General Hospital
Preston Renshawn, Chief Medical Officer at Avera Health Plans
Rachel Verville, Managing Director at BDO
Raghuram Mylavarapu, AVP, Healthcare at HTC Global Services
Rakesh Mathew, Interoperability Leader at HPP
Ranjana Singhal, Director, Enterprise Applications and Integration at SFDPH
Rebecca Jacobson, President at Astrata
Robert Rodgers, VP, Revenue Cycle at ATC/FFT
Robin Stoen, VP, Revenue Cycle Operations at Advocate Health
Rohit Taneja, Senior Manager at Deloitte
Ruben Prakash, Senior Director, HealthTech at UST
Ryan Graham, VP, Practice Operations & Value-Based Care at Privia Health
Ryan Monnin, SVP, Growth at Rhyme
Samantha Skaggs, Stars Improvement Lead at Humana
Sarah Armstrong, CEO at TREND Health Partners
Sarah Melander, Principal, Stars Care Coordination at Humana
Saras Agarwal,Associate VP at Newgen Software
Saurin Mehta, Senior IT Director at Scan Health Plan
Scott Barlow, CEO at Revere Health
Sheila Hyd, Senior Project Manager at UnitedHealthcare
Sripriya Subramanian, Project Director at HTC Global Services
Stephanie Nelson, Assistant Director at Vanderbilt University Medical Center
Steve Scharmann, System VP, Revenue Cycle at CommonSpirit Health
Sue Bihler, Executive Director, Middle Revenue Cycle at AdventHealth
Sule Baptiste, Director, Data Science at Healthfirst
Suzanne Wogelius, VP, Head of Product at Hyphen
Tarik Ketin, Senior Director at N1 Health
Tate McDaniel, Chief Growth Officer at ClarisHealth
Tim Capstick, Regional VP at Surescripts
Todd Flichel, VP, IT Applications at Medical Mutual of Ohio
Tony Begum, Business Architect at Blue Shield of California
Tony Murdoch, VP, Growth at Bamboo Health
Traci Massie, Senior Director of Outreach, Community Development and SDOH at Sentara Health Plans
Tracie Bernhard, RVP, Network Engagement and Experience at UnitedHealthcare
Tyler Creager, Senior Director, Growth, Performance & Cost of Care at The Cigna Group
Vandna Bhrany, VP, HEDIS Strategy at AmeriHealth Caritas
Walker Hale, VP, Sales, Provider at Clarify Health
Wendy Sale, Digital Health Innovation Director at Roche
Wil Limp, Program Director, Health Documentation Access at UW Health
Yvonne Dooley, COO at Harmony Park Family Medicine
Writer
Natalie Hopkins
Designer
Jess Wallace-Simpson
Project Manager
Joel Sanchez
This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.