How APIs Transform Payer Approaches to Member, Provider Experience

Selecting and deploying application programming interfaces (APIs) allows health plans to enhance how members interact with the healthcare system and how providers engage with payers.

As noted in the first installment of this three-part series, recent data show that API integration has become a top priority for most companies and is increasingly essential to an average of more than two-thirds of an organization’s revenue.

APIs are widely utilized for consumer-facing solutions: social media platforms employ APIs for communication and features, login and authentication APIs offer seamless sign-on experiences, financial institutions leverage APIs for remote banking, travel companies provide booking and scheduling APIs, and streaming services use APIs for content delivery. APIs are also crucial for microservices — a software development approach in architecture and organization in which software comprises small, independent services that communicate over well-defined APIs. The approach enables simpler updates to these constituent services rather than the entire application, promoting agility and scalability and avoiding disruptions.

According to Zelis Vice President of Enterprise Enablement, Matt Zelehowsky, health plans have a growing list of APIs to choose from that can drive their digital maturity and streamline their operations.

“The healthcare API economy has the potential to unlock significant value for healthcare consumers, providers, and plans. Imagine a plan striving to offer an integrated payments experience for providers, providing transparency and functionality for complete claim payments, encompassing both plan and member liabilities, complemented by operational claims efficiency recommendations,” he explains.

“Similarly, envision a member experience seamlessly aligning site-of-service and quality recommendations with prior authorization workflows,” Zelehowsky continues. “Through cross-partner API integration, previously unattainable, expensive, and time-consuming experiences become achievable.”  

Even health plans that have lagged behind their peers in digital transformation have the opportunity to adopt APIs.

“Health plans without a digital presence or those showing reluctance can tap into the potential of APIs and achieve easy wins,” says Zelehowsky. “The technology offers a straightforward path forward to improvement. For example, we have heard plenty of stories of plans that use older batch technology. While the data is accurate, it’s 3 to 5 days old at any given time. Providers are expecting moment-in-time updates, and when the experience isn’t real-time, it results in phone calls that are costly and time-consuming. APIs can bridge that gap to stop the calls and streamline self-service for providers.”

Choosing the right strategic technology partner is key to ensuring not only that a health plan will benefit from ease of integration but also gain access to a growing inventory of APIs and capabilities.

“In the face of the overwhelming burden of compliance and operational tasks, strategic partners offer a lifeline, enabling health plans to augment their value and enhance user experiences through APIs. This support becomes especially crucial when internal resources are stretched thin and cannot prioritize this critical work,” Zelehowsky maintains.

“Introducing new services builds momentum and appetite for greater API adoption,” he adds. “Looking forward, these are expected to take the form of network and transparency insights, which will provide accurate and timely information on payment status and healthcare providers, as well as APIs that offer claims pricing insights. Through this kind of API that is drawing serious interest from both payers and providers, health plans can gain access to information that helps them understand potential edits and the resulting pricing for a submitted claim in its current state.”
Existing and emerging APIs are coming to market that improve Healthcare Consumer engagement and experience:

Easy information access: APIs help health plan members quickly find accurate healthcare details like provider lists, coverage areas, drug lists, and cost estimates.

Real-time cost information: APIs connect pricing data and financial systems, letting members instantly check procedure, treatment, and medication costs based on their insurance.

Find providers: APIs assist in searching and choosing healthcare providers based on location, specialty, reviews, and costs so members can pick the right fit.

Book appointments: APIs link with scheduling systems for easy appointment booking and automated reminders for better care coordination.

Share health records: APIs ensure secure sharing of health info among systems, allowing members to access and exchange medical records for better coordinated care.

Stay healthy: APIs team up with fitness apps and wearables, giving personalized advice and rewards to support wellness and prevention.

Manage finances: APIs connect with financial aid, billing systems, and payments, aiding members in handling healthcare costs, accessing help, and managing bills.

The integration and effective implementation of APIs hold immense potential for health plans to transform member interactions across the healthcare system. API solutions offer a pathway toward increased transparency, personalized care, and operational efficiency.

A strategic technology partner’s role in API integration is vital, offering seamless integration, expanding API inventories, and bolstering digital ecosystems. Health plans without substantial in-house expertise can harness external proficiency to enhance their digital maturity and easily incorporate new capabilities. By embracing APIs, health plans can elevate member experiences and be ready for further digital transformation.

When looking for a modern healthcare partner, payers need to consider the following:

1. Do payers understand what their partner has to offer?

2. Have payers explored what technology support looks like?

3. Are payers informed about how their data is integrated and hydrated?

4. How will the partner’s services help with adoption and integration?

5. What is the partner’s roadmap and capabilities?

6. Does the partner’s ecosystem add velocity to a payer’s strategy?

It is critically important that health plans ask long-term questions of their modern healthcare partners.

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To learn more about the role of APIs in healthcare and how you can take advantage of them to extend your capabilities, click here to download “The Role of APIs in Transforming Healthcare” whitepaper.