Reimagining Payer-Provider Interactions: The Essential Building Blocks

In the evolving landscape of healthcare, providers and payers continue to grapple with significant administrative burdens that impact cost, efficiency, accuracy, care outcomes and ultimately, member experience. The time is ripe for a transformative paradigm that could not only alleviate these burdens but also enhance collaboration through intelligent software integration.

This visionary approach, leveraging advanced systems integration, interoperability standards, and generative AI technology, holds promise to address these challenges and revolutionize payer-provider interactions. The systems architecture in play also sets the stage for near-real time payments across various contract arrangements by making provider-payer transactions, involving claims and clinical encounters, more cohesive—a game-changer for healthcare.

Integrating Existing Workflows for Seamless Operations

The cornerstone of this innovative architecture lies in its ability to integrate seamlessly with existing workflows across the healthcare continuum. Here’s a snapshot of how that would work:

A patient would visit a healthcare provider who documents the clinical encounter in the Electronic Health Record (EHR) system. Upon signing the medical record, a provider module with generative AI models would seamlessly perform precise medical coding and billing, generating a standard 837 Electronic Data Interchange (EDI) claim. This claim would be sent directly to the healthcare payer interface, streamlining workflows and significantly reducing manual effort on the provider’s side.

On receiving the 837 EDI claim, the payer interface would check member eligibility, validate the provider’s National Provider Identifier (NPI), Tax Identification Number (TIN), and credentials. It would identify the optimal contract terms for claims adjudication, and after verification, the claims would undergo primary and secondary editing to ensure compliance with CMS and AMA guidelines, as well as medical and payment policies.

A standard 276/277 EDI claim transaction would be returned by the payer interface, detailing necessary adjustments. Once these adjustments are made and no further editing is required, the claim is adjudicated and processed for payment, ensuring accuracy within prepayment.

By deploying this payer interface for payment processing logic on the edge server of each provider’s infrastructure, the framework would minimize cybersecurity risks associated with centralized healthcare clearinghouses, which are prime targets for cyber-attacks. This edge module could be expanded to incorporate all payer adjudication logic specific to the provider’s reimbursement contract terms.

Enhancing Longitudinal Data for Better Outcomes

Parallel to the claims processing, the payer interface would integrate clinical records and claims data into the health plan member’s longitudinal data repository. This integration would support several critical functions including:

1. Risk Adjustment: The system would analyze longitudinal data to identify suspected health conditions and relay them back to the provider, informing future medical coding events and ensuring timely risk adjustment submissions for adequate premium funding.

2. Quality Measures: Utilizing the Healthcare Effectiveness Data and Information Set (HEDIS), particularly Electronic Clinical Data Systems (ECDS) measures, the system would run Clinical Query Language (CQL) measures against the longitudinal data in Fast Healthcare Interoperability Resources (FHIR) format. This process would close existing care gaps and identify new ones for providers to address.

Furthermore, advanced health plans could define their own CQL measures beyond what is available for download from the National Committee for Quality Assurance (NCQA)., These measures could be built to promote health equity by incorporating Social Determinants of Health (SDoH) data. They could also be used as value-based-care measures for providers in such payment arrangements

3. Prior Authorizations: The system would identify follow-up care needs and aim to auto-approve necessary authorizations. Providers would be notified to confirm care requirements, with all necessary approval evidence included in the confirmation request. If additional information is needed, the system would gather it from the provider during this process.

Pioneering the Future of Healthcare

This forward-thinking paradigm would minimize manual intervention, introducing automation that streamlines workflows for both providers and payers. It would reduce administrative burdens, enhance accuracy through automated validation and verification processes, and leverage data insights for proactive follow-up care, ultimately improving patient outcomes and experiences.

The future of healthcare would lie in the intelligent integration of advanced technologies that bridge the gap between providers and payers. By harnessing the power of generative AI and robust interoperability standards, we could pave the way for a more efficient, accurate, and patient-centric healthcare system. This visionary approach would not only transform administrative processes but also ensure that healthcare professionals could focus on what they do best—delivering exceptional care.