Industry Voices—Payer priorities on the journey to interoperability

Interoperability has been a persistent challenge as long as healthcare data have existed, and while provider organizations have faced the lion’s share of public scrutiny and regulatory intervention, payer organizations have seen their own data quality and portability hurdles over the years.

The recently finalized interoperability rules from the Office of the National Coordinator for Health IT and the Centers for Medicare & Medicaid Services, which put significant focus on payers and providers, may be the catalyst needed to finally address long-standing obstacles to improving payer-provider interoperability. 

The new rules mandate that health plans provide data portability, application programming interface (API) compliance with provider electronic medical record systems and patient data access—all of which are essential to harmonious payer-provider relationships. Secure and private access to health data for patients, providers and insurers could dramatically reduce many of the current system’s inefficiencies while improving safety, outcomes and affordability.

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To navigate the shift to true interoperability amid the COVID-19 pandemic, payers should pay attention to the following three areas in particular.

The advent of APIs. Because they enhance data portability, APIs like Fast Healthcare Interoperability Resources (FHIR) are a central component of the new interoperability rules. However, they also invite a host of opportunities for security loopholes as well as fraud, waste and abuse.

The concern over security vulnerabilities has been thoroughly discussed and addressed, including the ability to keep the data and sensitive information well-protected.

Payer organizations will need to carefully approach the API requirements to ensure member data are protected and monitor it vigilantly once in place. Insecure data can be systematically exploited: An extreme yet common example is submitting false claims to generate cash while polluting patient records with false information.

The proliferation of APIs can open new doors into protected health information and potential misuse. However, many organizations are now certified for high-level security and are constantly monitoring their systems for any vulnerabilities.

Telehealth’s ramp-up. The COVID-19 pandemic is exposing another set of potential issues for payers by forcing organizations to rapidly accelerate adoption of telemedicine, virtual care delivery and care in nontraditional settings like pharmacies and retail clinics. The urgency to move nonemergent care to alternative settings, and to treat those who have been potentially infected in isolated environments, has unfortunately created numerous opportunities for mistakes and confusion.

RELATED: Patients want to keep using virtual care after COVID-19 pandemic ends, survey finds

Providers have found it challenging to classify certain types of treatments, tests or diagnoses due to limited access to retrospective longitudinal information, and payers will have even greater difficulty determining what care occurred and what care should be reimbursed due to the virtual landscape.

Health plans are preparing for a potential uptick in erroneous claims associated with the coming changes, either due to unintentional errors or inappropriate activities. They are working to hone their best practices for detecting and addressing mistakes and potential gaps in care with these new care settings.

Data’s overdue revolution. The turbulent duo of interoperability rules and the pandemic are pushing much-needed improvements like broad-based data accessibility for public health and individual care. The rate at which payers and providers are being thrust into the new mandates and the COVID-19 chaos is overwhelming, yet it offers an important lesson on staying current, remaining agile and being positioned to pivot.

Earlier to adopt data aggregation than providers, many payer organizations still rely on applying codes and payment rules to data that are not comprehensive. The many cycles of M&A and industry consolidation have compounded the challenges of multiple technologies with highly complex business structures and an extreme diversity of product offerings and benefit structures.

RELATED: Anthem, CloudMedx launch digital tool to help employers, public health officials track impact of COVID-19

With a heightened focus on payers, the new interoperability rules are necessitating this shift and opening new ways to leverage health data and the insights it contains. The rules are also set up to ensure heath data are clean, accurate, comprehensive and consistent—and can be shared seamlessly between providers, payers and patients—helping drive long-overdue advances in how health data are captured, maintained and shared.

The shared path ahead

The new interoperability rules will break down significant barriers between payers and providers, dramatically improving the quality and quantity of information exchanged between the two. As a result, healthcare professionals will be better able to understand and address other long-standing challenges such as the cost of care, waste in care, gaps in care, unnecessary duplicative testing and more.

The sharing of financial, clinical and demographic data spanning multiple years with a single patient identifier can transform healthcare. Payers and providers can work together to address administrative burden and inappropriate waste. They can both lead the way to more robust risk identification and significantly move healthcare toward a more personalized and efficient system.

Emad Rizk, M.D., is chairman, president and CEO of Cotiviti and author of "The New Era of Healthcare: Practical Strategies for Providers and Payers."