Benefits of Payer-to-Payer Data Exchange Beyond Compliance

Insufficient data sharing continues to plague the healthcare industry, depriving health plans, providers, and members of crucial information for timely healthcare decisions. On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Final Rule (CMS-0057-F), and while this is a significant step towards improving member data exchange and delivering holistic care experiences, it is only the tip of the iceberg.

In the Final Rule, impacted payers are required to implement and maintain Payer-to-Payer application programming interfaces (APIs) to exchange clinical, claims and authorization data when a member moves between payers. In this blog we’ll outline the top three benefits of establishing secure connections with other health plans to not only meet mandatory compliance but improve long-term health outcomes, increase member satisfaction, and reduce costs.

1. Optimized Care Coordination & Tailored Treatment Plans

The ability for health plans to gather diverse electronic clinical and claims data on their members—including demographic and enrollment details, as well as medical histories—plays a pivotal role in advancing personalized patient care, optimizing administrative processes, and facilitating informed decision-making.

For example, clinical data can provide valuable insights into a member’s care journey within the healthcare ecosystem to help uncover gaps in care. This data includes information from electronic health records (EHRs), lab results, vital signs, diagnostic tests, treatment plans, medication records, and more. Accurate and complete clinical data can enable real-time visibility to help reveal member needs and provide opportunities for more timely interventions. For instance, upon receiving external clinical data, the current payer’s care managers can engage with members proactively. This involvement may include:

• Identify members overdue for screenings or vaccinations.
• Pinpoint medication discrepancies during care transitions.
• Recommend programs and track chronic disease management.

Having this type of proactive data exchange between payers ensures data availability for care coordination and also guarantees its presence from the moment a member joins the plan. This eliminates the need for health plans to wait for data to accumulate over 12-18 months, enabling them to seize valuable opportunities to engage with members promptly.

2.  Reduced Burden on Members

After switching health plans, members encounter the challenge of repeatedly articulating their medical histories. From medications to allergies and medical conditions, members find themselves providing detailed accounts as their new health plans grapple with the difficulty of seamlessly accessing comprehensive medical records from previous plans. The absence of easily accessible, mapped, and standardized clinical and claims data not only places the burden on members to verbally narrate their medical histories but also introduces inefficiencies and potential waste in the healthcare system.

Enabling direct data exchange with payers can effectively eliminate this challenge. When a member’s new health plan can obtain data directly from a member’s previous health plan, they are more likely to have current information, rather than depending on the member or waiting for them to visit their primary care provider (PCP). This approach also benefits the member by promptly activating their care team, especially for those who are most vulnerable with multiple chronic conditions or comorbidities that require ongoing management.

3.  Avoided Duplication of Tests & Services

Inefficient data exchange extends beyond inconvenience; it could lead to members undergoing redundant tests and procedures as new plans may require repetition to authorize specific courses of treatment. Additionally, members might face the prospect of changing doctors if their care teams are out-of-network for the new plans, amplifying the impact on everyone involved in the care journey. The need for improved electronic data transfer becomes not just a matter of compliance but a crucial step in minimizing waste and optimizing the overall healthcare experience for all health plan members.

How Availity Can Help You Facilitate Payer-to-Payer Data Exchange

At Availity, we understand the complexity of trying to facilitate data exchange across multiple data standard types and systems. Availity has created a centralized, one-to-many connection point exclusively designed for health plans to exchange clinical information.

Our first cohort started on August 22, 2023, to collaboratively identify and address pivotal decision points. The cohort has addressed two fundamental questions: first, to uncover any hidden challenges or pitfalls associated with payer-to-payer connections, and second, to determine the most effective and repeatable processes for establishing connections with other payers.

If you’re interested in learning more about how your health plan can go beyond mandatory compliance to unleash innovation, download our eBook! 

About the Author

After 20 years in Healthcare IT, Justin Howe now leads a series of Product teams at Availity that are focused on interoperability use cases centered on clinical data acquisition and driving FHIR adoption. Having worked in implementation, support and technical services roles in both an EDI clearinghouse and clinical data warehouse environments, Justin is a passionate advocate for reducing the overall burden on both providers and payers who rely on thoughtful approaches to solving difficult challenges.