How Payers Can Identify Partners for Automated Data Transfer

Defining automated data transfer

In some payer and provider partnerships, manual data collection still involves fax machines and photocopiers. Healthcare leaders, including CMS Administrator Seema Verma, have emphasized the need to abandon such technologies in favor of automation. Administrator Verma voiced a hope in 2018 that the healthcare system would be fax-free by 2020.

The healthcare system has become more digitized, but that does not necessarily mean it is becoming more automated.

When Wilder and others talk about automating data transfer, they are not simply referring to sending those files in a digital manner. Logging into a system to extract data and then digitally transfer it is still manual data collection, Wilder noted.

Instead, automated data transfer occurs when a health plan requests data on a patient through an aggregator. The aggregator then digs through its network and digitally drills down to the individual’s claims files to send back to the payer. The process can eliminate provider involvement almost entirely, apart from the initial data entry..

Automation is inching its way into several areas of the payer industry’s patient data exchange efforts. In some areas of the industry, it has completely supplanted antiquated data transfer methods. For example, in 2019, 80 to 90 percent of claims adjudications were executed through automation, McKinsey & Company estimated.

Still, only 25 percent of prior authorizations and less than 10 percent of medical record reviews were automated that year. While McKinsey & Company projected that those numbers could double or more than quadruple in the next five years, that leaves a lot of room for improvement.

One of the major benefits of automated data transfer is the speed at which it can occur. Through manual data collection, it can take days or even weeks to get the requested data back to the payer. In contrast, automated data transfer can take 15 to 30 seconds, Wilder said.

“Moving that down to seconds should be a dramatic improvement both for the providers and the patients as well as people getting that data,” Wilder explained.

“It’s a laborious process when it breaks on the manual side and everybody gets hurt in the process. The provider has more work to do. I usually have to help them hunt it down and get permissions and everything done. And, of course, the user of the data has a delay. So going digital hits three sides of that instantaneously.”

Automation also increases cost savings for payers. CAQH estimated in 2018 that payers could save up to $1.7 billion every year if they automated all of their administrative transactions. Savings were even greater for providers, with the healthcare system potentially keeping $11 billion each year if the claims administration process alone was automated.

But how do payers make this transition to automation across the broad spectrum of providers with which they work?

“The trick is the record locator,” Wilder said. “We built up a network of years of data about where patients' records are. So we can, at a central broker level, determine if the person, place, and period is appropriate to pass through that transaction and respond without having to have extra adjudication in play.”

With CommonWell’s tool, for example, when a payer requests data through aggregators that are in CommonWell’s network, the aggregators can hook into CommonWell’s interface, locate the claim for the individual or client by name, practice, and claim period, and deliver that data back to the payer without having to bother the provider for the information.

The system requires providers to opt-in, Wilder was careful to emphasize. Not all 16,000 clinical endpoints will immediately participate in CommonWell’s record locator solution. But there is significant excitement in the provider community around obtaining relief from the administrative burden of data exchange.

“It's not their expertise and their purpose to do the stuff that the payers do or vice versa. So getting that speed going, making it easier as well as still being secure with the right privacy controls,” Wilder added.

How to identify a partner for automated data exchange

Trust is typically a major barrier to this kind of partnership and for good reason.

“Doing the digital transactions with an automated broker in the middle requires all the connections and all the end points to trust each other,” Wilder explained.

Protecting patient data is a challenge and entrusting it to a network requires a good amount of faith in the organization navigating and delivering that data.

For this reason, payers should be looking for a partner with an infrastructure for data transfer that is well-tested. Evidence of years of successful data transfers are a good indicator that the automated broker is ready to engage with payer partners.

Another important aspect that can testify to an automated broker’s tested experience is whether the automated broker’s team has diverse skillsets and backgrounds.

A partnership with CommonWell, for example, includes a service provider and an operational provider with a leadership experienced in record copying. This gives the partnership a richer knowledge of the data exchange process, from the moment when record copiers put patient data into record form to the aggregators’ broad experience with various payer settings.

Furthermore, payers should seek an automated broker with not only a tested provider network, but also a broad one. If the automated broker does not have access to the provider data that a payer needs or may need in future provider partnerships, then working with that automated broker would not be a practical option.

“If we had tried this too early, we wouldn't have the network size and we wouldn't have had the trust worked out,” Wilder acknowledged.

To Wilder, there is a natural evolution from manual data exchange to automated data exchange that requires building out relationships in the industry one at a time.

CommonWell first built relationships with vendors that had access to large numbers of providers. Through successfully transferring millions of data files—currently, 22 million per week—over time, the organization built up trust.

Now, Wilder said that the organization is ready to bring payers into this dynamic. CommonWell’s payer data transfer pilot will come to an end in December 2020 so that the organization can start transferring with payers in 2021.

There is a lot of potential for automation in the payer industry.

In the future, Wilder sees automation leading to pushing content to payers. Instead of payer sending out a request, automation may be able to identify that a patient’s roster has been changed and will be able to send that information to the payer before the claim even arrives.

Processes like these may be in higher demand as the healthcare system rushes toward the CMS interoperability rule deadline which may require rethinking data transfer and developing new relationships with third-party vendors.