Points of Light 2023
Recognizing Successful Payer/Provider Collaborations

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• 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.

Build 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

Choose 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

Create 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

Utilize 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