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Payer/Provider Summit 2022 White Paper
Bringing New Energy and Direction to Payer/Provider Collaboration

author - Boyd Stewart
Boyd Stewart
author - Lois Krotz
Lois Krotz
July 22, 2022 | Read Time: 32  minutes

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An estimated $250 billion is wasted annually in avoidable healthcare administrative costs. Though many payer and provider organizations have resigned themselves to a lengthy process of managing authorizations, denials, and claim adjudication, both dream of a world where value-based care (VBC) puts payers and providers on the same page, with patients as their central focus. The goal of KLAS’ K2 Collaborative (aka the Payer/Provider Initiative) is to facilitate trust, collaboration, and alignment among payers, providers, and vendors in an effort to reduce friction and financial waste. To help realize this goal, KLAS hosted our second payer/provider summit in May 2022, which was attended by 104 leaders from across the healthcare industry.

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The purpose of the event was threefold:

circles icon1. Convene with a select group of payer organizations, provider organizations, and HIT companies to identify real, lasting solutions that reduce both administrative waste and payer/provider churn.

timer icon2. Accelerate knowledge and create transparency around the tools and processes leading to great outcomes.

handshake icon3. Collaborate to align incentives, create and maintain a measurement of performance (payer/provider measurement), and highlight success stories, or “points of light.”

This white paper covers three different sections, listed below. Click the links to jump directly to each section’s insights:

1. Findings from the summit discussions and poll

2. The goal, scope, and key findings of KLAS’ payer/provider measurement

3. An overview of the payer/provider/HIT vendor partnerships that received a 2022 Points of Light award for their efforts to collaboratively reduce friction between payers and providers

k2 collabrative logo

The Payer/Provider Initiative Is Now the K2 Collaborative

Evolving into a Collaborative

Forming the KLAS’ Payer/Provider Initiative was KLAS’ first step toward bringing payers, providers, and HIT vendors together to address the billions of dollars wasted each year in avoidable healthcare administrative costs. However, after hosting two successful summits, publishing the first Points of Light report, and distributing the first Points of Light awards, KLAS believes this initiative must evolve to reflect the collaboration necessary to solve mountainous insurance issues and improve the patient experience.

Why K2?

K2, a mountain located in the Karakoram mountain range in Asia, is one of the most difficult and dangerous mountains in the world for climbers to summit. Second only to Mount Everest in elevation, K2 has been summited only 377 times (as of February 2021), a mere fraction of the thousands of times Everest has been summited. More people have been to outer space than have reached K2’s peak.

Like the mountain, the friction and financial waste among payers and providers may feel insurmountable; however, KLAS (the “K”) and payers and providers (the “2”) can work together to summit these immense challenges. And the payoff will be worth the climb.

What about HIT Vendors & Other Organizations?

The success of the K2 Collaborative will ultimately be driven by payers and providers. However, just as climbers need the right equipment and guides to summit a mountain, these two parties also need help from HIT vendor partners and other organizations, who provide tools and experts that streamline the journey. For more about how vendors and other organizations are partnering with payers and providers today, read the Points of Light case studies at the end of this white paper.

Summit Discussion: Removing Hurdles Surrounding Value-Based Care

Summit participants were asked to discuss the following issues regarding the healthcare industry’s shift to VBC:

payer provider and vendor agreement on value based care issues

This data shows the following:

  • VBC is viewed as the preferred environment for payer/provider collaboration. Since the 2019 summit, an increased number of attendees agree that moving to VBC can do more to improve payer/provider cooperation than anything else. However, a majority of attendees believe that successful collaboration is still possible in a fee-for-service world. Provider attendees are the most optimistic about this possibility, followed closely by payer attendees and then more distantly by HIT vendor attendees.
  • Similar to 2019 results, most 2022 attendees agree that in 10 years, VBC will be the main care-delivery and financial model. However, they don’t believe VBC will be a silver bullet to solving payer/provider friction—all 2022 attendees agree that payer/provider relationships can still break down in the VBC world.
  • Across parties, confidence remains high that HIT vendors can play a key role in building alignment. Interestingly, among payer and provider respondents, agreement is lower than it was in 2019. Payers and provider organizations often tell KLAS that leveraging HIT vendors is difficult when there is a lack of trust and relationship between the payer and the provider organization.

Key Question: How Do We Remove Hurdles and Accomplish the Quadruple Aim?

To answer this question, summit attendees brainstormed during tabletop discussions. To move toward VBC and accomplish the Quadruple Aim, attendees suggested the following:

wrench iconStandardize: Standardize tools, definitions, shareable data, data formats, rules of engagement, and transactions.

target iconAlign: Work toward better alignment around incentives, goals, measurable clinical outcomes, services rendered, the payment of services, and the definition of risk.

handshake iconBuild trust: Start small and solve individual problems. There is more risk in the VBC world, so transparent communication and policies are critical.

share iconShare data: Explore ways to share data, including integrating claims with clinical data, using a bidirectional exchange, and determining how to implement more relevant and timely payer data into providers’ workflows.

patient iconGet patient buy-in: Measure patient satisfaction and provide more education support services and incentives for patients.

During the discussion, one group of attendees shared the following insight: “We are trying to redesign a fragmented system that was built with competing incentives. If we were building from scratch, we could figure things out more easily, and prior authentication likely wouldn’t have existed. Fee-for-service and value-based care are so fundamentally different. We are trying to build value-based care in a fee-for-service structure. We have to build with the patient at the center. We are trying to determine how to tear things apart and put them back together. We are solving micro problems, but we want to make sure things are scalable. The fee-for-service and value-based care models will have to live side by side for a while.”

What Are KLAS’ Next Steps?

award icon1. Increase number of Points of Light award recipients: We will continue to highlight the provider organizations, payers, and technology vendors who have found success via partnership and collaboration. We will be looking at innovation, creativity, and scalability to determine how these collaborations are improving the patient experience and reducing friction. To submit your story, please email us at

team icon2. Encourage regional collaboration: We will work closely with region-specific provider organizations and payers to identify how to increase partnership and reduce friction in their respective regions. This will include regional summits as well as qualitative and quantitative measurement.

shield icon3. Continue with the payer/provider measurement: We will continue to refine the payer/provider measurement and include region-specific findings with our national benchmarking data.

Payer/Provider Measurement: Creating Visibility and Transparency

As part of KLAS’ K2 Collaborative, provider organizations are invited to participate in the payer/provider measurement by anonymously measuring each of the top commercial payers their organization uses. KLAS will collect, aggregate, and analyze the data and then report the results back to the industry. In March 2022, KLAS completed a pilot study for our first payer/provider measurement. At the summit, we shared initial findings, and summit attendees were asked to provide feedback on the existing scope and quantitative and qualitative metrics to help fine-tune the measurement. The following sections outline the goal of the measurement, the current scope and metrics, initial key findings, and attendee feedback.

The Goal

The payer/provider measurement is intended to function as a facilitating mechanism—the actionable insights it generates can facilitate dialogue between payers and provider organizations, allowing them to learn from each other. Though this dialogue can be difficult, KLAS’ intent is to create an environment where payers and provider organizations can address pain points together and improve the status quo. We hope the solutions that come from these candid discussions will improve efficiency and reduce friction for both parties. Our goal is to build more trust and collaboration so that payers and provider organizations have a better foundation from which they can tackle tough missions together.

the goal of the payer provider measurement

To achieve this goal and measure partnerships, KLAS (1) captures payer and provider ratings that are turned into benchmarks and insights and (2) presents metrics, ratings, benchmarks, and insights online, down to the regional level (where available).

Current Scope of Payer/Provider Measurement

  • Data is from March 2021–March 2022
  • Participating organizations are located across the US but are mostly in the Midwest and Eastern regions; no particular region was a focus for this study
  • 11 participating provider organizations (KLAS will gather payer perspectives in future phases of the measurement)
  • 7 health systems with acute care and ambulatory care data
  • 2 health systems with only acute care data
  • 2 large ambulatory practices
  • 32 participating payer organizations (74 unique payer/provider partnerships measured)
  • All payers are commercial organizations

Quantitative Metrics and Definitions

sun iconAverage days to first payment: The number of calendar days it takes a payer to pay initially submitted claims. (Alternatively, the days of first payment for each claim averaged across all claims for the time period. First payments include all initial underpayments, overpayments, etc.)

Total days of first payment

Total number of claims remitted with first payments

piggy bank iconUnderpayment percentage by payer: The number of resolved claims that are underpaid over the total number of resolved claims or charges in the last 12 months. The numbers for resolved claims and underpayments are based on closed/zero-balance accounts for the time period.

Number of underpayments

Total number of claims resolved

denial iconDenials percentage by volume: The number of payments flagged as denials divided by the total number of payments posted during the reporting period. A payment is considered to be a denial if a denial follow-up record is created for the payment. The general denial areas include noncovered services, medical necessity, gaps in information/medical record requests, coordination of benefits, and eligibility. Subsequent denials are included, but claims are counted as one denial regardless of how many codes they may have. Duplicate denials (e.g., denial codes 18, CO 18, PI 18, PR 18) are excluded. KLAS provides a denial codes sheet for the denial codes requested.

Number of claims denied

Total number of claims resolved

calendar iconPercent of A/R over 90 days: The total billed A/R includes actively billed debit balance accounts (i.e., accounts that are open), series/recurring accounts, and accounts outsourced to a third party but not classified as bad debt accounts (e.g., early-out accounts and payment plan accounts). The total billed A/R excludes actively billed credit balance accounts, discharged not final billed (DNFB) accounts, in-house accounts, in-house interim-billed accounts (i.e., not billed at end of month), and any account not yet billed to the payer or patient/member (i.e., not considered part of billed A/R).

Dollar amount of A/R over 90 days (gross)

Total billed dollar amount of A/R (gross)

payment iconNet collection ratio (yield): The percent of actual net payments over the total expected net payments. The net collection ratio is for zero-balance accounts and excludes the patient portion for actual and expected payments.

Actual dollar amount payments recieved (net)

Total dollar amount expected payments (net)

Qualitative Questions about Payer Relationship

In addition to providing the quantitative metrics above, respondents were asked the following supplementary questions about their relationship with their payer partner.

1. For each of your top commercial payers, how would you rate the following (on a 1–9 scale)?

  • Proactivity in working to build trust
  • Transparency and understandability of rules or policies
  • Ability to share data bidirectionally
  • Efforts to reduce laborious manual processes or human errors (e.g., developing new technology, partnering with technology provider)
  • Ability to update their governance structures and processes to support innovation in a timely fashion
  • Timeliness of communication

2. What is the most impactful thing your payer has done to reduce friction and improve efficiency?

3. What is your payer’s biggest missed opportunity in terms of reducing friction and improving efficiency?

Key Findings

In the pilot study, KLAS intended to answer two questions: (1) Are there payers who are consistently performing better than others by collaborating with their provider partners? (2) Are there payers whose metrics are consistently lower than their peers’, and why? The data showed significant differences among the 11 provider organizations and 74 unique payer/provider partnerships.

average days to first payment
underpayment percentage
denials percentage
percent of ar over 90 days
net collection ratio yield

number 1No national payer organizations are leading the way with provider organizations, though provider-owned health plans stand out. Of the five payers with above average metrics, three are provider-owned health plans. All three payers report they had to go through a long process to establish mutual trust.

orange quote icon“Our payer definitely has a cool story. Two or three years ago, they used to be our worst payer, but they have come a long way. I think that is because of the approach we have taken with our payer; we have shifted to a risk agreement with a shared responsibility to care for patients and be a good steward of their healthcare costs. Removing administrative burdens, complexities, and waste on both sides should be top of mind for both payers and providers. If we can’t operate more efficiently, we aren’t going to make it.” —Senior director of financial services at a health system

metrics of payers with multiple provider partnerships

number The percentage of A/R over 90 days is higher than average for most of the payers who partner with multiple provider organizations. This is often due to payers requesting more information from provider organizations and then taking time to respond. Provider organizations do not speculate about why there are delays, but they mention the payers seem to be experiencing staffing shortages and backlogs.

number 3Of the payers who partner with multiple provider organizations, Payers 5 and 29 are mostly in line with or better than the average. Initial findings indicate that the provider organizations who partner with Payer 29 and report better-than-average metrics also perform well across all the payers they work with. These provider organizations report their success is being driven largely by their internal efforts—reported best practices include regularly communicating with payers, allocating the right number of resources to tasks, and retaining a payer consultant when needed.

blue quote icon“We have allocated appropriate resources around developing relationships, and we maintain constant communication with the payers. We make sure there are checks and balances and that the payers are applying the correct fee schedules and policies. It is great to have extra individuals who are working on these things, but at the same time, there is an added FTE expense for the extra layers we have built in.” —Executive director, patient financial services

number 4KLAS learned from the qualitative interviews that both healthcare providers and payers recognize that it will take time to resolve existing issues; however, they believe working toward a solution is well worth the effort and investment in the long run.

green quote icon“We had conversations around how much time things were taking and how many data sharing and administrative burdens there were. People believed that was the status quo. We looked at how many times provider organizations were moving people into offices and chart rooms and how often they were moving someone away from patient care and assigning them to payer administration. We hope to help reallocate staff back to overseeing patient care and not administrative burdens.” —Director of a large payer organization

Feedback and Next Steps

After KLAS presented the scope and metrics of the payer/provider measurement at the summit, attendees were asked to provide feedback on the scope, suggest additional VBC-based metrics, and refine the definitions of the current metrics. KLAS recommended that any newly proposed or updated metrics should be:

action iconActionable: Both parties should be able to use the data to have meaningful conversations and start making changes.

light bulb iconDigestible: There should be no information overload.

wrench iconStandardized: Organizations should be able to pull the metrics with clearly defined definitions and no ambiguity.

network iconEasy to pull: Provider organizations should be able to pull the same data regardless of their technology/services partners.

Summit attendees provided a lot of helpful feedback, and the most mentioned suggestions are listed below. KLAS intends to finalize next steps and begin broader data collection based on the updated metrics and scope.

approval iconUse data from standardized measurements of patient satisfaction (e.g., NPS, CMS Star ratings, HCAHPS)

data iconPull patient experience data (e.g., estimated costs, patient access to care, no-show rates, quality of care)

measure iconMeasure administration efficiency, especially prior authorization timeliness and turnaround (e.g., time from authorization to approval, percent of authorization denials overturned, delays in treatment due to payment/prior authorization reasons)

2022 Points of Light Awards

payer provider points of light recognition 2022 logoAs part of the K2 Collaborative, the annual Points of Light awards celebrate success stories—or “points of light”—from payers, providers, and vendors who have partnered to reduce costs and inefficiencies and improve the patient experience. Fifteen such collaborations were awarded a 2022 Points of Light award, and overviews of their strategies and outcomes are shared below to illustrate the art of the possible. Additionally, each collaboration includes a review from KLAS’ payer/provider advisory board, which consists of five well-respected experts in the industry: Glenn Raley (Director of Provider Interoperability Product Management at Humana), Neil Kulkarni (VP of Customer & Clinician Experience Solutions at Highmark Health), Rachel Verville (Chief Revenue Cycle Officer at Allegheny Health Network), Todd Craghead (VP of Revenue Cycle at Intermountain Healthcare), and Victoria Losinki (VP of Quality & Risk Adjustment at Blue Cross and Blue Shield of Minnesota). Each review from this group—dubbed “The Fab 5”—details the uniqueness of the case study and the organizations’ impact on the industry. See the Points of Light 2022 report for in-depth case studies of each collaboration.

Collaboration 1: Consolidated Patient Billing Leading to Higher Satisfaction, Increased Collections, and Reduced Waste

Healthcare organization: Anonymous

Payer organization: Anonymous

Technology partner: Cedar Gate Technologies

Executive Summary: Seeking to provide a simplified billing experience for patients and reduce administrative costs, Payer Organization 1 and Healthcare Organization 1 teamed up with Cedar to create a unified patient bill that combines the health system’s billing with the payer’s explanation of benefits. The payer and healthcare organizations also integrated their customer service. By working collaboratively and leveraging Cedar’s patient financial experience technology, the organizations were able to achieve improved member/patient satisfaction, higher collection rates, and reduced costs. The participants emphasized the importance of building trust and letting go of past narratives that didn’t serve the common goal.

Fab 5 Review: The uniqueness of this case study is the payer’s and provider organization’s commitment to come together to collaboratively craft an approach that puts the patient/member needs at the center of the solution. As the case study mentions, it is often difficult for these stakeholders to put aside biases based on past experiences or assumptions. The ability to eliminate biases and build trust was essential to ensuring that the crafted solutions truly did support patient/member needs. The confusing billing experience described in the problem statement is a long-standing, extraordinarily frustrating dynamic that has long created distrust and confusion for patients/members. The healthcare industry must come together to eliminate this unnecessary point of friction that negatively impacts patients/members, often when they are in the middle of a stressful health crisis. This approach is a winner.

Collaboration 2: Payer/Provider Collaboration Reduces Credentialing Turnaround and Improves Denials Process

Healthcare organization: Spectrum Health

Payer organization: Priority Health

Technology partner: None

Executive Summary: Spectrum Health partnered with Priority Health to tackle two areas of inefficiency that were causing employee frustration and reducing productivity: the credentialing turnaround time and the denials process. A workgroup that included representatives from both stakeholder organizations was formed to identify areas of friction in these processes and to implement solutions. The results include improved member/patient satisfaction, increased staff productivity, and reduced denials. The collaborators note that success came as they were willing to fully commit to the project and work amicably on a shared objective.

Fab 5 Review: Most notable in this case study is the demonstrated willingness by both the payer and provider organization to engage in active conversation in order to solve a problem. The process of credentialing a new provider involves several handoffs which are dependent upon each other. Provider organizations are eager for new providers to begin offering care soon after the onboarding process. There is increased friction on both the payer and provider side when this process breaks down. This case study demonstrates that when effective collaboration exists between the payer and provider organization, positive outcomes can be achieved, which will increase overall patient/member satisfaction.

Collaboration 3: Streamlined Chart Retrieval Reduces Waste and Provider Abrasion

Healthcare organization: Novant Health and Anonymous

Payer organization: Anonymous

Technology partner: Moxe

Executive Summary: In response to a growing volume of clinical-data requests, the collaborators in this case study worked together to streamline and automate the chart-retrieval process. Using a 100% digital chart-retrieval solution from Moxe, Payer Organization 3 is able to access complete, accurate clinical data from Novant Health and Healthcare Organization 3. By bringing all stakeholders to the table and creating relationships of trust, the collaborators have been able to improve satisfaction among members/patients, reduce frustration and manual work for the healthcare organizations, and improve ROI for the payer.

Fab 5 Review: It is unique that the payer and provider organization worked together to evaluate, select, and implement a technology vendor partner to support chart retrieval and transfer protocols. This approach ensured that the technology solution met the needs of both sides, that the data would be normalized appropriately as part of the exchange, and that all payer and provider stakeholders negotiated accountability and responsibility. The largest impact on the industry is the reduced effect of administrative burdens on patient care. As noted in the summary, increased time, effort, energy, and cost focused on administration detracts from investments in care. Minimizing the burden of data exchange will allow payers and provider organizations to focus on the value in value-based arrangements, thus improving quality and patient health outcomes.

Collaboration 4: Avoidable Denials Reduced via Early Detection of Claims Errors

Healthcare organization: University of Iowa Hospitals & Clinics

Payer organization: UnitedHealthcare

Technology partner: Optum

Executive Summary: Administrative costs in healthcare are now in the trillions. Hoping to reduce these costs, the three stakeholders in this case study worked together to incorporate UnitedHealthcare’s payment rules into the University of Iowa Hospitals & Clinics’ billing solution. This allows the health system to catch errors before claims are submitted, reducing rework and saving on administrative costs. The collaborators emphasize the importance of continued collaboration to make sure the suggested edits continue to be refined and expanded.

Fab 5 Review: Allowing Optum to work with UnitedHealthcare to build payment rules inside of the provider organization’s system is somewhat unique. While many provider organizations work to model payment rules in their systems, they are often challenged due to complicated plan designs. Running the claims against payer rules provides insights into deficiencies that could delay processing and increase the likelihood of denials. The biggest impact this case study will have on the industry is helping others accelerate claims adjudication and reduce administrative burden.

Collaboration 5: Automation of Prior Authorization Process Reduces Manual Workload for Critical Resources

Healthcare organization: Conway Medical Center

Payer organization: Palmetto GBA

Technology partner: Cedar Gate Technologies

Executive Summary: Seeking to reduce the manual effort required to obtain prior authorization, the collaborators in this case study worked together to create a SMART on FHIR link between Conway Medical Center’s EMR and the software used by Palmetto GBA. The link simplifies the process for both the payer and healthcare organizations and frees up resources to work on critical pandemic-related tasks. The stakeholders are now working to expand the automation to additional procedures and healthcare organizations.

Fab 5 Review: I believe this study is unique because of the way the groups worked collaboratively as equals to achieve mutually beneficial outcomes. This builds trust between payers and provider organizations, and that trust is often overlooked. Reducing the administrative burden and integrating that into the provider workflow has a real impact on the industry’s bottom line.

Collaboration 6: Innovative Care Management Program Used to Cut Costs and Transform Lives of Super-Utilizers

Healthcare organization: The Queen’s Health System

Payer organization: Anonymous

Technology partner: Health Catalyst

Executive Summary: To better serve individuals experiencing homelessness—who are often super-utilizers of The Queen’s Health System’s inpatient and emergency department (ED) services—the stakeholders in this case study worked together to enable the healthcare organization to first identify these individuals and then provide community health workers to help connect them with available community resources. The resulting program has been extremely successful for all parties involved—first and foremost for the patients and the clinicians who serve them.

Fab 5 Review: The payer’s willingness to (1) offer funding to a provider organization for the initial program without being part of a risk-sharing agreement and (2) provide needed information directly to the provider organization is a unique approach. Additionally, the provider organization’s ability to engage other payer partners and make similar arrangements without the initial payer organization having any restrictions is an open, beneficial approach that other organizations can model as they move forward (not everything needs to be propriety or competitive). Additionally, given that the provider organization was outside of a value-based agreement, they could have seen this concept as destructive to their ED and refused to move forward with the model. Yet they didn’t, and their commitment to patients and their community outcomes should truly be commended. The provider organization maintained a personal connection between the navigator (i.e., community health worker) and the patient while maintaining a small caseload for each navigator, and the patient could be comfortable and build proficiency; this differentiated approach is extremely valuable. If the organizations determine that the model is truly scalable across other locations, lines of business, and diagnoses while maintaining the high-touch model with low caseloads for the navigators, that could change the way payers and provider organizations think about what is truly scalable.

Collaboration 7: Quadruple Aim Is the Goal for Provider and Payer Organizations’ Separate Use of AI-Enabled Prior Authorization Solution

Healthcare organization: Essentia Health

Payer organization: GuideWell

Technology partner: Olive

Executive Summary: The technology in this case study is used by Essentia Health and GuideWell to automate the prior authorization process and thus reduce manual processes and delays in care. This case study is unique in that the highlighted healthcare and payer organizations pursued their prior authorization automation independently of each other. Their perspectives demonstrate how the technology is able to reduce friction for both the provider and payer markets without direct collaboration or contracting.

Fab 5 Review: When the organizations used automation and focused on improving documentation quality, patients benefited from faster decisions on prior authorizations and fewer denials, and physicians saw greater efficiency.

Collaboration 8: Improved Data Integration Generates Quality and Financial Benefits for Payvider Organization

Healthcare organization and payer organization: Community Health Plan of Washington (provider-owned health plan)

Technology partner:

Executive Summary: In order to provide better care and build trust between their payer and provider divisions, Community Health Plan of Washington (a provider-owned health plan) worked with to build a 360-degree patient view based on both claims and clinical data. They then used the data to create a pay-for-performance program that rewards providers for value-based behaviors. The program has led to both quality and financial improvements.

Fab 5 Review: Though standards exist for data types, they cause additional expenses in the healthcare industry, and emerging efforts to create new standards won’t be effective for a long while. In this case study, there was an intentional focus on data quality and on creating shared normalized data that improves each party’s trust in the data. It is very interesting to see the approach of utilizing SDOH data for risk programs. As the industry shifts to focus on health equity, this approach would become a significant enabler.

Collaboration 9: Bundled Payments for Maternity Care Improve Quality, Drive Down Cost

Healthcare organization: Vanderbilt Health

Payer organization: Metro Nashville Public Schools

Technology partner: Cedar Gate Technologies

Executive Summary: With the costs for maternity care rising, Metro Nashville Public Schools partnered directly with Vanderbilt Health to create a bundled payment program for their maternity population. Technology from Cedar Gate Technologies enables the smooth, efficient administration of the program, resulting in high satisfaction for all stakeholders, including the patients themselves.

Fab 5 Review: Layering a value-based reimbursement component on top of an existing fee-for-service model is an interesting opportunity and a way to help employers, payers, and provider organizations continue their journey toward broader value-based reimbursement agreements. Additionally, the way the bundles were designed to simplify and change other administrative processes (such as prior authorizations) empowers physicians and nurses to operate at the top of their license. The organization’s ability to build provider buy-in and engagement in the model and their willingness to be held accountable for outcomes sets a foundation for accelerating the shift to value-based reimbursement across their system. This type of model may work for an employer that is primarily located in a certain geographic location and can allow them to work with a provider organization focused in that geographic location. However, it also poses challenges in how scalable this approach is. The health systems’ ability to drive provider engagement and buy-in is something that can be further evaluated and replicated for other systems looking to embark on that transition.

Collaboration 10: Prior Authorization for Imaging Automated via CDS Technology

Healthcare organization: UVA Health

Payer organization: Anonymous

Technology partner: Change Healthcare

Executive Summary: UVA Health realized that the government-mandated clinical decision support they used when placing imaging orders for Medicare patients could potentially be leveraged to expedite the prior authorization process while also improving providers’ imaging order patterns. As a result, the organization partnered with Change Healthcare and one of their commercial payers to leverage the clinical decision support mechanism for non-Medicare patients and expedite the prior authorization process, leading to significant benefits for patients, ordering providers, and the payer organization.

Fab 5 Review: I believe the unique aspect of this study is the acknowledgement that the entire health system needs to be willing to participate. These solutions are proving valuable, but they will only bring about true change with scale and broad adoption. Agreeing to repay for unnecessary imaging so that there is shared risk is crucial. As the lessons learned indicates, these relationships help to increase trust across provider organizations and payers, and the long-term result is the industry will be better focused on outcomes and reducing the overall cost of care.

Collaboration 11: Bidirectional Data Exchange Leads to Increased Ability to Close Care Gaps

Healthcare organization: HSC House Calls

Payer organization: Humana

Technology partner: athenahealth

Executive Summary: As the industry shifts to value-based reimbursement, everything revolves around quality of care. And providing a high quality of care requires increased collaboration and data exchange between payer and provider organizations. In this case study, SC House Calls’ EMR vendor used FHIR APIs to create and automate a closed-loop exchange of clinical data between the organization and Humana. Outcomes of this collaboration include reduced administrative burden, improved clinical outcomes, and improved provider satisfaction.

Fab 5 Review: The intent of value-based payment models is to align incentives to ensure clinical quality in support of optimal patient outcomes. Sadly, current mechanisms used to gather data to support quality and outcomes often obscure that goal, and the health and care needs of patients/members are pushed to the background. This solution supports the needs of both payers and provider organizations and is built around ensuring that both payers and provider organizations can adequately understand the patient/member population. Creating more streamlined, comprehensive, and bidirectional data sharing between the two parties allowed for appropriate risk stratification, intervention, and quality care management. This is a significant need across the industry. A care gap that is not closed, or a chronic condition that is not tightly managed, could result in a serious health issue for a person, triggering a negative contractual result. Putting patient/member needs first will lead to overall improvement in financial outcomes. And leveraging technology to improve workflows, assist providers, and allow for more visibility by payers is fantastic.

Collaboration 12: ePA and RTPB Technology Used to Reduce Unnecessary Prior Authorizations, Increase Price Transparency

Healthcare organization: UCSF

Payer organization: Anonymous

Technology partner: CenterX

Executive Summary: Lack of patient-level insurance coverage data at the point of care can add to the administrative burden for provider organizations, pharmacy benefit managers, and payers and lead to high prescription costs for patients. The technology in this case study helps reduce these issues by confirming whether prior authorization is needed and embedding patient-specific formulary information into the prescriber’s workflow. The results have been a win for all stakeholders involved.

Fab 5 Review: Embedding the Rx authorization process within the EMR workflow provides a unique approach to managing and improving this process. Human error is reduced by leveraging technology to determine whether an authorization is required or to help manage the process of determining what alternatives should be considered based upon the health plan in play. The biggest impact this case study has on the industry will be accelerated turnaround times for required authorizations, which improves overall outcomes and reduces costs.

Collaboration 13: Collaboration Creates More Automated Prior Authorization for Orthopedic Practices

Healthcare organization: OrthoVirginia and Anonymous

Payer organization: Humana

Technology partner: Cohere Health

Executive Summary: To combat a prior authorization process that was burdensome to patients, providers, and payers, the stakeholders in this case study worked together to provide a more automated process and incorporate suggested care plans into the provider workflow. The stakeholders kept the patient as the center of their focus, and the collaboration has not only led to faster access to care for patients but also reduced the administrative burden for the payer and provider organizations.

Fab 5 Review: This work demonstrates that trust, partnership, and technology can improve patients’ timely access to care while creating medical savings and decreasing administrative burden and workload associated with prior authorization.

Collaboration 14: Holistic View of Patient Data Enables Better Identification of and Care Management for High-Cost Patients under Capitation

Healthcare organization: Baton Rouge General Medical Center

Payer organization: Healthcare Highway

Technology partner: Lightbeam

Executive Summary: The stakeholders in this case study collaborated to bring together clinical and claims data in one holistic view of the patient. This data is used to identify high-cost or high-risk members covered by capitated contracts so that these individuals can be referred to Baton Rouge General Medical Center’s comprehensive care clinic. The care management provided by the clinic is designed to optimize health outcomes and reduce costs.

Fab 5 Review: This approach is very interesting and unique because the payer and provider organization were willing to collaborate and work together in a different way, use the same external solution, and share and bring together payer and provider data at scale. Additionally, the clearly defined accountabilities and the level of communication and coordination across the case managers and care coordinators enabled the successful outcomes. This case study is an example of how organizations can take steps to build trust and work toward value-based reimbursement arrangements. This is a model that other payers and provider organizations can use to start building new capabilities and establishing a path toward value-based reimbursements and population health management.

Collaboration 15: Administrative Simplification through Clinical Data Exchange

Healthcare organization: Mayo Clinic

Payer organization: Blue Cross and Blue Shield of Minnesota (BCBSMN)

Technology partner: Epic

Executive Summary: When prior authorizations and claims are being processed, requests for additional clinical information creates administrative burden for payers and provider organizations and delays patient care. In this case study, the collaborators leveraged Epic’s clinical data exchange system, Payer Platform, to share timely clinical information about shared patients/members. This connection has given BCBSMN direct access to medical records, allowing them to find needed clinical information rather than requesting medical records from Mayo Clinic. There are now decreased denials, and both organizations have experienced positive administrative impacts.

† This Points of Light case study was presented at the 2022 payer/provider summit; thus, it has not yet been published by KLAS or reviewed by KLAS’ advisory board. The case study will be published in KLAS’ 2023 Points of Light report.

Summit Attendees

Anthony Cunningham VP of Revenue Cycle, Atrium Health
Ajit Sett ACA, President & Co-Owner, Savera Health LLC
Alan Hutchison VP of Population Health, Epic
Amy Stevens General Manager, Provider Performance and Value Innovation, Innovaccer
Andrei Gonzales VP, Value Analytics Product Management Change Healthcare
Anthony Comfort EVP, Product Management & Innovation, VisiQuate
Ashley Bieck MPA, VP of Provider Experience & Workflow, Optum Care
Ashley White MBA, VP of Population Health, LifePoint Health
Becky Phelps Regional Vice President, R1 RCM
Ben Reigle Founder, RCM Leaders Forum
Beverly Barrett Director (West Region), IQVIA
Bob McSweeney President, Press Ganey Associates
Bradley Tinnermon VP of Revenue Cycle and Revenue Integrity, Banner Health
Carmen Jacobson BSN, RN, Senior Director of Business and Clinical Informatics, CARTI
Chris Sawicki Chief Sales Officer, Cedar Gate Technologies
Christophe Chefd’hotel PhD, International Business Leader—Oncology Clinical Care Operations, Roche Information Solutions
C.J. Stimson MD, JD Senior VP of Value Transformation, Vanderbilt University Medical Center
Courtney Guernsey FHFMA, CHFP, CRCS-I, CRCS-P, Senior Director of Patient Financial Services, Spectrum Health
Dan McMaster Chief Strategy Officer & Director, 3M Health Information Systems
Dan Wilson CEO/Founder, Moxe Health
David Eagle Chair of Legislative Affairs and Patient Advocacy, New York Cancer & Blood Specialists
David Hines Executive Director of Benefits, Metro Nashville Public Schools
Dennis Weaver MD, Chief Clinical Officer, Oscar Health
Diane Gabrielsen HIA, Executive Consulting, Executive Consulting—Health Plan
Doug Henkel MBA, SVP of Growth, Arcadia
Eric Herbek Chief Managed Care Officer, Mass General Brigham
Gina Kim Chief Product Officer, Cohere Health
Glenn Raley Director of Provider Interoperability, Humana Inc.
Grant Kocer Director of Contracting and Payer Relations, Mayo Clinic
Hemant Goel CEO, nThrive
Howard Brill Senior VP of Population Health Management & Quality, Monroe Plan for Medical Care
Jamie Madrinich RN/CMCN, Pre-Service Authorization RN Manager, Essentia Health
Jana Danielson VP of Revenue Cycle, Nebraska Medicine
Jared Sorenson Global Business Partner Director, 3M Health Information Systems
Jeff Burbank Executive Vice President, Provider Commercial Leader, Datavant
Jennifer Lehmann System Director of LSFV Program, University of California Health
Jennifer Styron EVP and Chief Executive Officer, CARTI
Jeremy Friese MD, President, Payer Market, Olive
Jerry Shultz President, Lightbeam Health Solutions
Jim Gaffney Chief Strategy Officer, Ensemble Health Partners
Jim McDermott SVP, R&D, Epic
Jim McDonnell Executive Director, Olive
Joan Butters CEO, XSOLIS
Joe Johnson President & COO, Palmetto GBA
Joe Kachelski CEO, WISHIN
John Keith CEO, Exponential AI
John Lee SVP, Chief Medical Information Officer, Allegheny Health Network
John Pigott General Manager, Payer and Life Sciences, Innovaccer
John Yount Chief Innovation Officer, nThrive
Jonathan Zimmerman CEO, Holon Solutions
Judson Ivy Founder & CEO, Ensemble Health Partners
Julianne Migely Senior Director, National Payer Accounts, IQVIA
Kari Cornicelli CPA, EVP, CFO, Phoenix Children’s
Katie LeBlanc VP of Strategy and Partnerships, Providence
Leslie Antunes Chief Growth Officer, Availity
Lynda Rowe Senior Advisor, Value-Based Markets, InterSystems
Mackenzie Clark PharmD, APh, BCPS, BCGP, Pharmacy Supervisor, UCSF Health
Maggie Barlow MHA, Senior Director, Huron
Mary Mirabelli CHFP, SVP of Corporate Strategy, HFMA
Matt Hawkins CEO, Waystar
Matt Schaefer President, CenterX
Michael Marchant Director of Interoperability, UC Davis Health
Mike Kaminaka Chief Growth Officer, Holon Solutions
Mitch Murri Owner, Mitch Murri Consulting
Mitchell Josephson CEO, Health Data Management Group
Motti Edelstein VP of Revenue Cycle, Allina Health
Nele Jessel MD, VP, Chief Medical Officer, athenahealth
Nicole Antonson VP, Advanced Analytics Business Solutions Leader, Anthem
Nikhil Mendhi President & Chief Operation Officer, Exponential AI
Nirav Shah Strategy and Operations, New York Cancer and Blood Specialists
Pamela Griese Senior Business Systems Analyst, WPS Health Solutions
Patrick Mason MHA, Director Revenue Cycle, INTEGRIS Health
Patrick Nelli President, Health Catalyst
Paula O’Brien Senior Applications Analyst, WPS Health Solutions
Perry Sweet EVP, Client Operations, Waystar
Pete McCabe CEO, Datavant
Peter Brawer EVP, Chief Strategy Officer of Hospital System Partnerships, Healthcare Highways
Rachel Verville Chief Revenue Cycle Officer, Allegheny Health Network
Rebecca Preston MD, JD, CMO/CEO, HighCare Health
RJ Allgood VP of Payer Strategy, INTEGRIS Health
Robin Free AVP, Palmetto GBA
Russ Thomas CEO, Availity
Sachin Garg MD, MAS, Global Head of Value Delivery, Roche Information Solutions
Sandeep Wadhwa MD, MBA, Global Chief Medical Officer, 3M Health Information Systems
Sarah Crymes MHSA/MBA, Executive Director, Customer Success Management, athenahealth
Seth Cohen President, Cedar
Simon Dobretsov AVP, Revenue Integrity and Payer Contracting, CARTI
Stephen Bernard EVP Customer Management, R1 RCM
Steve Scharmann System VP, Revenue Cycle, CommonSpirit Health
Sule Baptistr Director, Data Science, Healthfirst
Suresh Kumar Dasagranthishanmugam Chief Transformation Officer of M&A, Exponent Health
Suzanne Cogan General Manager, Payer Solutions, Press Ganey Associates
Terrie Handy VP of Revenue Cycle, Legacy Health
Terry Blessing EVP, Operational Integrity, VisiQuate
Tina Foster VP Data Insights and Impact, Anthem
TJ Nicolaides MBA, Senior Director of Product Management—Population Health, Health Catalyst
Tobin Lassen EVP, Chief Bundle Solutions Officer, Cedar Gate Technologies
Todd Craghead Revenue Cycle Executive, Intermountain Healthcare
Todd Flichel Director of Information Technology, Medical Mutual of Ohio
Todd O’Connell President, New York Cancer and Blood Specialists
Tom Merrill Principal, Redstone
Tracy Melekian Managing Director, Huron
Victoria Losinski PharmD, PhD, MBA, VP of Quality and Risk Adjustment, Blue Cross and Blue Shield of Minnesota
Will Limp MS, RHIA, Manager of HIM, UW Health
Current Time Inside Cache Tag Helper: 10/1/2023 12:39:06 AM and Model.reportId = 2943


author - Sarah Hanson
Sarah Hanson
author - Jessica Bonnett
Jessica Bonnett
author - Andrew Wright
Project Manager
Andrew Wright
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