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payer to payer data exchange
 

Pioneering the Next Frontier of Bidirectional Data Exchange

 

4.30.2024 By Michael Taylor, Senior Clinical Product Owner at Availity

 

For the last few decades, data silos and fragmentation have been a persistent challenge within and between healthcare systems. The gradual transition from paper-based record keeping to electronic health records (EHRs) has paved the way for a more interconnected highway, yet substantial hurdles remain in data traveling seamlessly from one destination to another. Challenges revolving around how data is structured and standardized, packaged, and shipped are just the tip of the complexity iceberg in facilitating data exchange.

Over the years, the Centers for Medicare & Medicaid Services (CMS) have released mandates and regulations to help drive the adoption of standards like Fast Healthcare Interoperability Resources (FHIR®) and the United States Core Data for Interoperability (USCDI). The now-finalized Interoperability and Prior Authorization Final Rule (CMS-0057-F) is one of the more recent initiatives requiring impacted payers to implement and maintain Payer-to-Payer APIs to exchange clinical, claims and authorization data when a member moves between health plans.

However, making encounter and clinical data available in USCDI through a FHIR API is just the first step. The real challenge for health plans lies in building and maintaining the highway system needed for data to flow seamlessly, and in real-time. This structural process involves establishing direct connections with payers and enacting the technical steps for data retrieval. The Health Level Seven (HL7®) International Da Vinci Payer Data Exchange (PDex) Implementation Guides offer implementation guidance for health plans to fulfill API requirements and conduct the exchange of health-related information for members who wish to transfer their data when transitioning between payers.

The Da Vinci PDex Implementation Guides serve as use case implementation roadmaps for health plans to navigate the process. However, payers who have attempted to establish connections in the real world have found that there are some hidden challenges that the implementation guides cannot capture. Given the final rule's requirements, the need for extensive collaboration, and the potential increased effort for multiple connections, pursuing this without an experienced partner will be challenging. Moreover, building an internal system can be costly and time-consuming, especially when factoring in the ongoing maintenance of these connections and the necessity for health plans’ internal teams to stay current with evolving standards.

 The Next Frontier – A Centralized Connectivity Hub

At Availity, we understand the complexity of trying to facilitate data exchange across multiple data standard types and systems. We are working with a select cohort of payers to pioneer the establishment of the inaugural set of payer connections within our cutting-edge Availity Connectivity Hub, which aims to minimize the reliance on costly and time-consuming point-to-point connections. Through months of collaboration, we’ve identified the most effective and repeatable process for establishing connections with other payers. Our process involves a meticulous three-step sequence initiated by a member's request for their new plan to retrieve historical information from the old plan, as further detailed below. 

 

1: The member opts in for their new health plan to request their data from their previous plan. Subsequently, three potential scenarios can unfold:

 

  • The member then provides their former Member ID number and the name of their previous insurance carrier to their new health plan.

     

  • The member doesn’t know their former Member ID number but provides the name of their previous insurance carrier to their new health plan. The new health plan then facilitates a PDex member-match operation. 

     

  • The new member doesn’t know their former Member ID number or the name of their previous insurance carrier. The new health plan facilitates a member-match across payers to try to locate available data. 

 

This third scenario is not required by the mandate to support, but instead represents the embodiment of a payer putting the member first, assisting them in getting their data to stay with them wherever they go.

 

2: Once member-matching has been completed, a Payer-to-Payer API call is made to the Availity Connectivity Hub, enabling confirmation of the member's information with the old plan. Secondly, security clearance is obtained through a token request, ensuring authorized access to the member's data.

 

3: The new plan requests and receives the member's information from the old plan, with all data seamlessly managed through the Availity Connectivity Hub. 

 

This structured process ensures data accuracy, security, and tackles challenges with innovative solutions like person-matching features and ongoing discussions on broader applicability.

At Availity, our exploration of the complexities of the data exchange framework underscores the urgency for a transformative approach. The innovation of the Availity Connectivity Hub, coupled with our exclusive payer-to-payer cohort, presents a unique avenue for health plans to break free from the constraints of fragmented information.

Seize the opportunity to lead, collaborate, and shape the future of healthcare connectivity with Availity. Don't wait for mandatory enforcement; let's collectively drive positive change, ensuring timely, informed decisions that elevate healthcare outcomes for health plans, providers, and members alike.

If you're ready to be at the forefront of this transformative journey, click here to learn more or to schedule a meeting with our team. Together, let's redefine the landscape of healthcare data exchange.

 

 

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