KLAS: 6 Vendors That Aim to Resolve Payer-Provider Friction

Arcadia

Arcadia sought to resolve data integration issues for a health plan.

Community Health Plan of Washington (CHPW)—a health plan with over 282,000 members that also operates 21 community health centers, over 140 clinics, and more than 100 hospitals—needed to integrate patient data and improve the organization’s pay-for-performance program.

The payer partnered with Arcadia to build a population health management platform, pulling from different EHRs, laboratory data, and social determinants of health data. The Arcadia platform also tracked quality performance and could perform risk adjustments as well as support pre-visit planning.

Quality scores at CHPW improved after implementing the tool. The payer advised that other organizations that might follow in their steps be aware of potential biases in population health predictive algorithms that are based on historical data.

CHPW has also leveraged population health management tools in order to address and integrate social determinants of health data.

Cedar

Cedar came up twice in the report as a vendor that payers leaned on to address prior authorization and patient billing.

For its prior authorization solution, Cedar teamed up with Palmetto GBA—a health plan serving 20 million members in South Carolina—and Conway Medical Center—a provider that employs more than 100 providers.

Manual prior authorizations burdened Palmetto GBA’s staff as well as Conway Medical Center’s healthcare providers. To solve this issue, the vendor instituted a SMART FHIR link that drew important information from patient EHRs and delivered it to the payer for five specific procedures.

Conway Medical Center noted that it did not interact with the payer much for this process.

The partners found that this solution diminished prior authorization return time to under 48 hours and lowered the overall administrative burden. The partners urged other organizations to find the right stakeholders for this solution early on in the process and to find a vendor that is very familiar with CMS requirements.

However, Palmetto GBA and Conway Medical Center stated that there were still manual parts of the prior authorization process. The entire process had not become automated through this solution, as anticipated, and this required the organizations to be flexible.

For Cedar’s patient billing solution, an anonymous payer organization and provider organization identified that patients were dissatisfied with their explanation of benefits, so the partners sought to simplify it, as many industry stakeholders have tried to do.

The partners decided that they should merge the explanation of benefits and the provider bill into one document. Cedar helped the organizations with the streamlining process, which resulted in a 20 percent boost in collections and member and patient satisfaction rates that exceeded 90 percent.

Cedar is using the technology that streamlined provider bills and explanation of benefits to address patient intake and preprocessing issues. 

Cohere Health

Cohere Health sought to automate prior authorization for orthopedic practices.

The vendor worked with Humana, OrthoVirginia, and an anonymous healthcare organization in order to prevent disconnect between payers and providers and to make the prior authorization process less burdensome.

The partners adopted electronic submission. OrthoVirginia and Humana worked together to build a library of CPT codes, which enabled automation. Providers can sign into the Cohere Health platform to submit a prior authorization which often will identify and display the appropriate questions to include in the document. The partners integrated the solution into provider workflows.

The platform offers a reason for why a request was denied or approved and allows providers to view the status of a request.

Actuaries found that the process led to 40-50 percent lower administrative burden for Humana and a 10 to 15 percent increase in savings for Humana. Additionally, it resulted in 70 percent faster access to care and 38 percent less administrative burden for providers in terms of time spent on prior authorizations.

The partners advised other organizations pursuing this route to start by applying the process to a small number of procedures before expanding.

Lightbeam

Lightbeam worked toward improving care management and risk identification for high-cost patients in capitation models.

The vendor collaborated with Baton Rouge Medical Center and Healthcare Highways, a health plan with 50,000 members. Healthcare Highways’ goal was to identify members who qualified for a capitated billing, referral program.

Using Lightbeam’s solution, the partners brought together EHR and claims data, which the system used to organize members into high-cost categories. The solution also tracked the payer’s return on investment and offered provider dashboards.

As a result, A1c quality measure compliance grew by 13 percent and payer costs for high risk patients dropped by 5 to 8 percent.

Moxe

Moxe worked with an anonymous payer organization, an anonymous healthcare organization, and Novant Health to reduce waste and provider abrasion during chart retrieval.

The organizations automated the chart-retrieval process using an API-first process and standardized the data format. The provider retained the power to set up release restrictions.

As a result, payer return on investment improved as did member satisfaction. There was less manual work involved in chart retrieval—fewer phone calls, faxes, and follow-ups. Access to care improved and staff assignments in the provider organizations stabilized. 

The partners recommended that payers who plan to leverage this solution group chart-retrieval processes under a single department. Also, partners may need to incorporate cybersecurity and privacy entities in the process.

Olive

Olive worked with GuideWell—a health plan with 3.3 million members—and Essential Health—a healthcare organization with 2,100 physicians—in order to create a prior authorization solution that leans on artificial intelligence.

GuideWell and Olive partnered to incorporate artificial intelligence into the electronic authorization request process. The artificial intelligence solution assesses whether a request has enough information and, if not, automatically informs the provider.

The software also tells providers whether a prior authorization is required so that they do not submit unnecessary prior authorizations.

As a result, GuideWell processed 27 percent fewer unnecessary prior authorizations and prior authorization decisions are 48 percent faster.

The partners noted that GuideWell already had standardized prior authorizations prior to implementing the solution and that the payer had a 275 transaction for claims. Some experts have recommended that Medicare Advantage implement the X12 275 electronic claim attachments transaction model to help standardize prior authorizations.