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Points of Light 2023
Recognizing Successful Payer/Provider Collaborations

author - Boyd Stewart
Author
Boyd Stewart
author - Joshua Jensen
Author
Joshua Jensen
author - Aurene Wilford
Author
Aurene Wilford
 
April 12, 2023 | Read Time: 19  minutes

Innovative partnerships between payers, healthcare organizations, and HIT vendors have the potential to revolutionize healthcare processes and outcomes. KLAS’ annual Points of Light awards celebrate success stories—or “points of light”—achieved by payers, healthcare organizations, and vendors who have partnered to reduce costs and inefficiencies and improve the patient experience.

In total, 25 such collaborations were awarded a 2023 Points of Light award, and their strategies and outcomes are shared in this report to illustrate the art of the possible. It is our aim to help payers, healthcare organizations, and vendors collaborate more effectively to resolve some of healthcare’s biggest points of friction. This report’s Executive Overview provides a high-level summary of the types of challenges these collaborations tackled and the outcomes they achieved; the full report provides an in-depth case study of each collaboration.

points of light recognition 2023A note about award methodology: Points of Light awards are given to payers, healthcare organizations, and HIT vendors who demonstrate close collaboration that leads to shared outcomes. KLAS validated each submission via a standard set of questions administered during in-depth interviews with representatives from all relevant stakeholders. Interviews were conducted from July 2022 to March 2023.

Points of Friction (and the Technology Used to Tackle Them)

The collaborations highlighted by the 2023 Points of Light awards represent real progress that has been made in reducing administrative inefficiencies and improving patient outcomes. To achieve these goals, the collaborations targeted a variety of areas, the most common being (1) interoperability between payer and provider organizations, (2) the prior authorization process, and (3) value-based care.

types of challenges tracked

Interoperability and clinical data exchange top of mind as part of the focus on value-based care: Transparent data sharing between payer and provider organizations is critical to the success of value-based care initiatives. The collaborations with this focus were able to give both parties access to a more comprehensive view of patients’ health, thereby improving care coordination; reducing care gaps, medical errors, and duplicative care; and improving the accuracy of quality measure submissions, all of which contribute to lower costs and higher reimbursements.

Automated prior authorization a clear win in terms of efficiency: Obtaining prior authorization for medications, imaging, and procedures can be a significant source of administrative inefficiency and patient frustration. The partnerships that focused on streamlining this process leveraged strategies such as artificial intelligence, interoperability, and clinical decision support to standardize the submission process, reduce manual workloads, improve data sharing, increase visibility of patient coverage, and improve speed to access for patients.

Success with value-based care requires technology investment: Recognizing the infrastructure required for success with value-based care, the partnerships that focused on this area upgraded their technology stacks to include care coordination systems and data analytics tools, improving access to real-time data and outcome and utilization patterns to allow them to accurately assess patient risk, reduce costs of care, and inform HEDIS quality measures and Star ratings. In these collaborations, stakeholders had to be willing to learn new operational and financial processes and new technologies to effectively support and sustain bundled-payment programs.

Wide Variety of HIT Solutions Used to Address Points of Friction

types of hit solutions

The wide variety of technologies being used to address payer/provider pain points speaks to the complexity of the task at hand and the fact that there are often multiple options for achieving outcomes. Our hope is that examining these options will help other organizations identify technologies that might be helpful in their own strategies. Which option is best will largely depend on the collaborators’ resources, budgets, relationship, and timeline. The table below outlines the specific challenge each group of collaborators was trying to solve, the action plan created, and the outcomes achieved.

Overview of Points of Light Collaborations—By Type of Challenge Tackled

collaborators key

Interoperability/clinical data exchange

Case Study 1

collaborators case study 1

Manual, inefficient processes and back-and-forth communication regarding denials and prior authorizations created administrative burden for payer and provider organizations

Identified common pain points and shared goals and then used technology to improve interoperability and clinical document exchange to streamline administrative processes

Outcomes: Automation of processes reduced manual workloads and improved clinical workflows, decreasing payer medical record requests and associated phone calls. Reduced denials on physician and hospital billing, resulting in more claims being paid. Led to more trust and stronger partnership between payer and provider organizations.


Case Study 3

collaborators case study 3

Administrative challenges associated with risk adjustment audits and value-based care

Created an automated, standardized retrieval process for records needed to complete managed care audits, with technology enabling bidirectional data sharing

Outcomes: More accurate risk adjustment scores and more streamlined submission of risk adjustment data to CMS, increasing provider and payer reimbursements. >300% increase in number of retrieval requests for care management audits that healthcare organization can handle per day thanks to more efficient processes. Improved patient outcomes. Improved patient privacy and security compliance.


Case Study 4

collaborators case study 4

Complexity of moving to value-based care and lack of visibility for providers into patients’ full medical history, including payer claims data

Mapped payer claims data to a data model and integrated it in real time into provider workflows at the point of care, improving their ability to accurately assess a patient’s health

Outcomes: Significantly faster, easier ingestion of claims data by provider organization to inform population health tool and update provider cost and utilization dashboards, thus improving reimbursements. Reallocation of FTE due to automated release of information. Improved identification of chronic conditions that were previously unknown. Improved medication reconciliation and documentation of patient acuity, HCC management, and risk management.


Case Study 5

collaborators case study 5

High preemptive denial rates and time-consuming manual work caused by a lack of interoperability between payer and provider systems; resultant variation in medical necessity determinations

Implemented a centralized utilization management model backed by AI and machine learning that interfaces with the provider EMR to provide a numeric prediction of where each patient falls on the medical necessity spectrum

Outcomes: More streamlined utilization management process, using predictive analytics to automate case determination, improve alignment of status determination, create more efficient and collaborative payer/provider workflows, and reduce administrative friction. Reduction in provider case review time from 15 minutes to 5 minutes; 38% reduction in payer case review time, ensuring faster resolution of claims submissions.


Case Study 6

collaborators case study 6

Lack of interoperability in the claims-monitoring process, compromising staff productivity and contributing to staff burnout

To reduce manual work associated with claims monitoring, stakeholders combined API technology from the payer with robotic process automation (RPA) technology to deliver claim statuses directly into the healthcare organization’s EMR

Outcomes: Improved efficiency of payer and provider workflows, reducing touch points and the administrative burden. Accelerated claims turnaround times, with 90% of claims statuses between the organizations delivered electronically with no manual intervention. Fewer denials and faster payment collection.


Case Study 7

collaborators case study 7

Slow progress with population health management initiatives and value-based contracts due to lack of access to relevant patient information, including claims, clinical, and financial data; financial pressure to reduce costs

Used technology to collect, aggregate, and integrate claims, financial, and operational data and gain better insight into a variety of cost, utilization, and performance metrics

Outcomes: >90% improvement in the efficiency with which the payer and provider organizations are able to analyze their data, improving the organizations’ ability to understand how they are performing in risk-based contracts. Reduced readmission rates and ED visits, leading to reduced per-member per-month costs.


Case Study 8

collaborators case study 8

Lack of real-time visibility into clinical information at the point of care, leading to higher readmission rates, ED visits, and tension between payers and providers; delayed communication from payers to providers regarding key clinical information

Embedded automated care alerts directly into providers’ workflows, notifying them when patients experience health events that require action from the PCP

Outcomes: Reduced administrative burden for provider organization due to having access to real-time data at the point of care. Improved connectivity between local hospitals and PCPs. 50% reduction in hospital readmissions. Reduced ED visits, resulting in 46% reduction in related costs for one of the provider organization’s physicians.


Case Study 10

collaborators case study 10

Inability of providers to address care gaps due to lack of comprehensive patient data; inability of payers to meet CMS requirements and accurately report on patient risk

Designed, developed, and implemented an EMR-agnostic solution that includes SMART on FHIR application that accurately exchanges bidirectional, up-to-date information on patient risk scores, medication adherence, and care gaps

Outcomes: Reduced friction between provider and payer due to improved visibility of patient medical history. Improved awareness of chronic conditions that may require provider assessment and improved ability for treatment plans to be informed in real time by in-workflow data. More accurate reimbursements due to improved data transparency. Improved patient satisfaction due to reduction in unnecessary re-examinations of previously performed services.


Case Study 15

collaborators case study 15

Siloed data that makes it hard for providers and payers to have a complete clinical picture, hindering their ability to close care gaps and meet HEDIS quality metrics

Mapped non-standardized clinical data into one unified longitudinal medical record that gives both the payer and the provider the ability to track patients across settings and over time

Outcomes: More efficient clinical pathways with payer and provider organizations, resulting in improved accuracy of annual HEDIS quality measures. Pilot-supported clinicians outperformed the control group on multiple patient health measures—e.g., A1C control checks were 35% higher, BP control for diabetic patients was 125% higher, retinal eye checks were 35% higher, and colorectal screenings were 5% higher.


Case Study 16

collaborators case study 16

Payer lacked easy, real-time access to members’ clinical data to inform their HEDIS quality measures and NCQA submissions; high administrative burden for provider organization in responding to payers’ requests for data

Automated the release-of-information process using APIs to extract data in various formats from provider EMR; data was then standardized and sent to the payer, reducing the administrative burden and facilitating the identification of care gaps

Outcomes: Streamlined clinical processes, with majority of release-of-information requests now automated, meaning they can be processed in seconds and human resources can be allocated to other work. Provider organization able to supply their providers more detailed monthly reports with aggregated data. Improved accuracy of annual HEDIS quality measures, resulting in increased CMS ratings and payer reimbursements. Improved data security as there is an automated audit trail and visibility into all data requested and sent.


Case Study 23

collaborators case study 23

Multiple interoperability issues in sharing and accessing data for managed care efforts, negatively impacting quality measure reporting as providers lack visibility into patient care gaps

Automated payer-provider data exchange to integrate real-time payer data into clinical workflows, thereby enabling providers to identify gaps in care needed for HEDIS requirements

Outcomes: Increased closure of care gaps, with more patients obtaining access to care, including the sickest patients with chronic conditions like diabetes or hypertension. Resulting improvements in quality measures. Increased peer-to-peer mentorship on best practices that improve care.

Prior authorization

Case Study 2

collaborators case study 2

High administrative costs associated with manual, labor-intensive processes for authorizing referrals and clinical procedures, compounded by siloed workflows between payer and provider organizations

Improved the speed and transparency of authorizations through FHIR API that enables bidirectional data sharing and an automated, in-workflow authorization process

Outcomes: More efficient, automated workflows that facilitate timely authorizations. Cost savings for payer and provider organizations through significant reduction in manual processes. Improved patient outcomes via more timely access to care.


Case Study 9

collaborators case study 9

Complex prior authorization process required time-consuming manual processes that delayed patient care

Automation of submission and follow-up for authorization requests enables providers to complete tasks in their EMR workflow

Outcomes: Improved efficiency of the utilization management process, with 50% of authorization submissions receiving instant authorization. Reduced workloads as authorization submissions take providers 1–2 minutes per submission (previously took 7 minutes). Turnaround times from request to appointment date have dropped from 25–30 days to 10–15 days. Reduction in denials for physician and hospital billing.


Case Study 13

collaborators case study 13

Costly, manual prior authorization process created administrative burden and patient frustration with delayed access to care

AI technology connected to payer’s utilization management system and integrated into EMR, automates the clinical documentation, clinical assessment, and recommendation processes

Outcomes: More efficient clinical workflows, reducing administrative burden and time spent on utilization management. Fewer denials and an increased number of authorization requests approved on initial submission, resulting in faster access to care.


Case Study 14

collaborators case study 14

High cost in terms of time and money for provider and payer organizations in managing prior authorization process, with delays creating patient frustration

Interoperability standards from HL7’s Da Vinci Project used to create end-to-end FHIR solution and automate the submission of prior authorization requests from within the EMR

Outcomes: Improved workflows for payer and provider organizations, leading to faster authorization decisions. Many determinations can be returned in seconds, compared to a previous turnaround time of 3-5 days. Reduced administrative burden for stakeholders, and faster access to care for patients.


Case Study 19

collaborators case study 19

Delayed access to medication due to inefficient prior authorization process, with lack of standardization in submission process and how medication dosages are reported

Integration of payer/provider workflows through automation and rule logic that allow providers to do real-time prescription benefit (RTPB) checks, reducing payer/provider workloads and standardizing submission process

Outcomes: Quicker patient access to medications due to streamlined processes and workflows, improved alignment between payer and provider organizations, elimination of backlog, and 20%–25% reduction in case cancellations due to fewer authorization requests submitted for medications that don’t need prior approval.


Case Study 24

collaborators case study 24

Providers did not always know which services required prior authorization; workflows to determine when an authorization was required were manual and time consuming

Developed a database and in-workflow self-service app to enable providers to determine in real time whether an authorization is required; portal dashboard in the EMR workflow provides the status of all authorizations the provider has requested

Outcomes: More efficient payer/provider workflows, with fewer touch points and improved alignment. Faster access to medication for patients due to providers receiving information in real time and making fewer interpretation errors.


Case Study 25

collaborators case study 25

Complexity of cardiovascular care pathways coupled with the need to coordinate care among multiple providers led to delays in diagnosis and care, increased administrative burden at handoffs, and increased costs

Adopted utilization management portal that helps providers choose evidence-based care paths for patients, notifies them of care gaps to address, and brings automation to the prior authorization workflow

Outcomes: High provider satisfaction due to improved administrative experience; reduction in denials and peer-to-peer reviews; reduction in turnaround times from 5–7 days to about 2 days. Higher than anticipated adoption of automation process due to provider ease of use.

Value-based care

Case Study 17

collaborators case study 17

Low medication adherence among vulnerable and underserved patients with chronic conditions, including diabetes, hypertension, and high cholesterol

Developed a medication adherence tracker to identify high-risk patients who have not picked up or refilled medications; practice staff contact identified patients to discuss and resolve barriers to adherence, including utilizing vendor’s resources to help resolve SDOH barriers

Outcomes: Patients who received an intervention were 20 times more likely to fill their prescription than those who did not. Following implementation of the tracker, medication adherence Stars measures increased year over year by 52% to 5.0 in 2019.


Case Study 18

collaborators case study 18

Manual, labor-intensive process of extracting and exchanging data required for VBC contracts created an administrative burden for payer and provider organizations

Implemented automated chart-retrieval process that consolidates information into one standard, consumable file and includes dynamic privacy-centric filtering logic to protect patient confidentiality

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


Case Study 20

collaborators case study 20

Difficulty of diagnosing and treating high-risk cardiovascular patients; need for data, transparency, and partnership to design and operate value-based contracts to incentivize care best practices

Collaborated on a bundled payment program that prioritizes optimal treatments and locations of care to meet the clinical, financial, and patient satisfaction goals of each partner

Outcomes: A win for payer, provider, and patients through introduction of bundled payment program, which reduced costs for all parties. Improved preventive care and appropriateness of care, which in one example shifted 97% of services to more cost-effective office and outpatient settings and reduced costly hospitalizations.


Case Study 21

collaborators case study 21

Gap-closure rates below desired levels were impacting health outcomes and reducing reimbursements for the payer and provider organizations

Implemented program aimed at incentivizing staff on a monthly basis for completing value-based actions that help physicians identify and close care gaps at the point of care

Outcomes: Increased teamwork, staff morale, and staff engagement, leading to more success in reaching goals of value-based programs. Increase in closure of care gaps and improvement in quality measure performance. Payer reported an ROI 3x the value of the initial investment.


Case Study 22

collaborators case study 22

Lack of access to timely, accurate patient-encounter data negatively impacts HEDIS scores, Medicare Star ratings, and risk scores for patients covered under capitation and VBC contracts, reducing payer and provider reimbursement

Implemented technology to give payer access to updated, real-time patient-encounter data, enabling them to identify care gaps and ensure their members receive needed care, including preventive screenings

Outcomes: More efficient processes, leading to improved timeliness and accuracy of payer’s regulatory submissions and improved accuracy of risk adjustment scores. Reduction in human errors and improved risk adjustment scores, leading to increase in provider reimbursements. Payer staff reported shift in workload from more administrative tasks to more advisory, customer-focused tasks.

Patient billing

Case Study 12

collaborators case study 12

Complex bill-pay process for patients/members, leading to low satisfaction rates with health plans and associated delayed or unpaid bills that add to provider organizations’ existing financial pressures

Implemented electronic self-pay technology to simplify the bill-pay process and send patients more transparent bills outlining their claims, EOB data, and HSA and deductible balances; technology also enables self-pay

Outcomes: Increased patient payments and improved patient engagement in the payment process. Increase in self-service payments. 88.5% of patients report satisfaction with the new billing system.

Remote patient monitoring (RPM) & care management

Case Study 11

collaborators case study 11

High cost of hospital and ED visits for ACO-attributed patients with high-risk chronic conditions and difficulty of providing them with comprehensive post-discharge care

Implemented deviceless RPM program to better manage patients with chronic conditions post-discharge; patients are contacted daily or twice a week to self-report biometrics, with results outside of normal thresholds triggering real-time alerts

Outcomes: Improved communication processes between payer and their members. Reduction in unnecessary PCP visits and improved patient care outside office hours. Improved patient outcomes due to member health improvements, resulting in payer organization achieving decreases in their monthly cost of care per member.

Points of Light: Most Common Outcomes Include Improved Provider Experience, Improved Efficiency/Processes, and Improved Care/Patient Experience 

The collaborations highlighted in this report have achieved a variety of outcomes. The most common include:

  • Improved healthcare organization experience: Both administrative staff and clinicians have benefited from more automated workflows, and better understanding of the prior authorization process has reduced denials and decreased delays in claims being paid. Organizations have also seen more accurate reimbursements due to better identification of care gaps and have reported improved data visibility and reduced friction due to more alignment in payer/provider workflows.
  • Improved efficiency/processes: With payer/provider workflows being more streamlined and less siloed, stakeholders report improved efficiency in the administrative tasks between their organizations.
  • Improved quality of care/patient experience: Greater alignment between payer and provider organizations and greater data visibility also lead to faster access to care, better quality of care, and a more satisfactory patient experience.
points of light top outcomes achieved through collaboration

Key Lessons Learned

Any efforts to improve collaboration and alignment between payer and provider organizations require active participation from all stakeholders. Organizations looking to implement their own collaborations can benefit from those who have already walked the path. The 25 collaborations examined in this report yielded many best practices, but the four key lessons outlined below emerged as the most common. Additional best practices can be found in the full case studies.

icon 1Build Partnerships of Trust and Collaboration

  • Focus on common ground and have a collaborative, innovative mind-set
  • Commit to investing the needed resources (human, financial, technological), and be clear about the availability of these resources
  • Foster open, regular communication throughout all phases of the initiative
  • Choose partners who are highly committed to achieving the project’s goals and are accountable for the long haul
  • Be agile and willing to adjust workflows based on the needs of the project

icon 2Choose Technology Partners That Offer Robust Technology and Are Proactive

  • Look for technology that is sustainable and scalable; vendors need to create technology that works with SMART on FHIR, CDS Hooks, and non-FHIR APIs
  • Make sure AI capabilities are informed by robust clinical work driven by in-depth clinical consultations

icon 3Create the Groups and Governance Structures Necessary for Success

  • Establish governance groups comprised of representatives from all relevant stakeholders
  • Empower stakeholders to make workflow and organizational changes
  • Ensure all operations personnel are included in pre-implementation discussions
  • Foster involvement from the healthcare organization’s executive and medical leadership

icon 4Utilize Data to Drive Improved Outcomes

  • Start with a small data subset for a defined population
  • Understand the data needed to meet CMS requirements and HEDIS quality measures in VBC contracts
  • Enable a common data exchange process regardless of where the information originates
  • Analyze preliminary progress data, have data security checks, and know your performance targets by having measurable metrics of success
  • Benchmark your performance against other organizations in closing quality care gaps
author - Elizabeth Pew
Writer
Elizabeth Pew
author - Jess Wallace-Simpson
Designer
Jess Wallace-Simpson
author - Joel Sanchez
Project Manager
Joel Sanchez
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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. © 2025 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.