Rhapsody Health Solutions Team

What Is Possible When You Bridge the Gap Between Payer and Provider Data

New interoperability rules from CMS and ONC and other megatrends like consumerism and value-based care are adding momentum to help close the interoperability chasm between provider and payer data.


The importance and the value of closing this gap becomes more urgent when we envision what is possible in a world where clinical, claims, and even public health data connect to drive better insights into care, greater efficiency in care delivery, and more delightful experiences.  


Making this vision a reality will require hard work, and we have a long way to go. A recent survey of 189 payers, providers, hospitals, and vendors found that the biggest challenges they perceive to compliance with information sharing regulations are:  

  • Lack of data standardization (47%)
  • Lack of technical interoperability (44%)
  • Poor shared data quality (44%)

This makes sense because data interoperability has always been hard, requiring collaboration across organization boundaries, and reconciliation of terminology. The great news is that it is easier than it used to be to integrate fit-for-purpose healthcare technologies. When implemented, all of this is possible. 


Seamless Authorizations 

When everyone has access to common data, standards of care can more easily be agreed to. and automating authorization will be simpler. Instead of being able to process automated pre-authorizations of care in a few limited use cases, it will be possible in all but the most complex or controversial procedures. This will make the authorization process much less resource-intensive and expensive for payers, much faster and more predicable for providers, and a non-issue for consumers. 


Delightful Consumer Experiences 

The benefits to the patient experience will extend far beyond eliminating the headache of navigating the authorization process. In a world where everyone knows what care is appropriate and approved and what the patient’s financial responsibility is, surprise billing will only be a thing when patients are forced to get care in an unexpected setting, a scenario currently being addressed in the COVID relief bill passed in December 2020. 


Beyond that, well-integrated claims and EMR data will result in much more robust patient/member portals that include financial as well as clinical and wellness tools. Consumers will be empowered to engage more deeply and proactively in their care. This may include participating in tailored preventative wellness programs or scheduling care strategically to optimize use of deductibles and HSA/FSA dollars. 


Actualized Consumer-driven Healthcare 

The other big benefit for consumers will be the ability to assume much more control over their healthcare. By having complete transparency into their health record they can effectively advocate for themselves and the people they manage care for. 


Once interoperability rule compliance becomes ubiquitous and people have seamless access to all their health data (via a combination of FHIR and HL7 V2/V3), they will be empowered to grant access when they want access granted. This access also opens up whole new horizons for value-added apps and services. 


Public Health Preparedness 

The COVID-19 pandemic has helped highlight the need for better interoperability. If we invest in connecting data in meaningful ways, we will be prepared to respond to any future public health crisis. Testing data, vaccination status, co-morbidities, and other critical data points are critical to public health. 


These kinds of longitudinal or historic data elements can get lost today as patients switch providers or health plans, but better interoperability will also mean better retention across transitions of care. With health data that is more comprehensively updated and shared, and patients more in control of their own data, teams will have easy access to complete health information when the need arises. 


Better Coordinated Care 

When patients and their care teams have reliable access to comprehensive data, they can make more informed well-rounded care decisions and ultimately optimize care for each patient. They can also work more efficiently with specialists and other experts temporarily brought into the patient’s circle care of care. 


Within Sight 

Achieving these things has been a long-standing challenge for healthcare organizations for many reasons. As it stands now, many organizations are expected to comply with the latest ONC/CMS interoperability rules by sharing data via the FHIR standard. 


The compliance deadline is stressful for payers and providers given that only 18% of providers report having expertise in FHIR-based healthcare data exchange models and only 36% of payers report expertise in this area. The good news is roughly 74% of vendors report having expertise in FHIR-based healthcare data exchange and are therefore equipped to support payer and provider technical teams.  


More good news: amazing tools, services, and dedicated organizations are ready to help close interoperability gaps. As health systems and payers rush to comply with the new ONC rules, they will need expert assistance. Partners who are well-versed in both FHIR, HL7 V2/3 and integrating EMR lab and ADT data with payer data formats like X12 will be best positioned to help them achieve that vision.

Learn more about payer interoperability solutions from Rhapsody.

Payer Workflows: Prior Authorization Decision Support and Payer Coverage Decision Exchange 

FAQ’s: Payer Interoperability and CMS Compliance

DaVinci Project Aims to Boost Payer-Provider Interoperability 

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