August 24, 2021 - 228 views|
By using a data store vs. an API façade to exchange health data, payers can go beyond compliance, to exceeding member experience expectations.
What if all the health data your insurer has collected about you could be transferred seamlessly to your next insurer? Imagine prior authorizations rolling over automatically, instant enrollment in care management, elimination of phone calls, faxes and wait time.
These are just a few of the possibilities that can become reality as payers work to meet the Payer-to-Payer Data Exchange requirements of the Interoperability and Patient Access final rule. Health plans will soon have the opportunity to receive a member’s historical care information from a previous plan and apply workflow and analytics to improve the enrollment process, utilization management, risk modeling and more.
Complying with the Payer-to-Payer Data Exchange requirement presents a significant operational challenge, evident from the FAQs and other support documents prepared by The Centers for Medicare & Medicaid Services (CMS). Health plans should be prepared to manually send and receive member data from other plans through a Secure File Transfer Protocol (SFTP), among other means, to support compliance with and meet the Jan. 1, 2022 Phase 1 deadline.
Broadly speaking, there are two ways to comply with the Payer-to-Payer Data Exchange requirements: an API façade or a data store. Although the façade is the quicker and easier approach, the data store is far superior in terms of the greater benefits it offers over the long term.
Here’s how each option breaks down:
When plans consider their options for complying with the Payer-to-Payer Data Exchange requirements (as well as other regulations like the Transparency in Coverage rule or the No Surprises Act), they should identify growth opportunities that go beyond meeting minimum compliance requirements. While data access requirements and compliance options are primarily technical in nature, the plan’s choices for meeting these requirements will significantly affect their members and operations.
By building a data store rather than using an API façade, plans have opportunities to improve the member experience with analytics.
Consider this scenario: A new member has been using a smartwatch app to manage her health. At enrollment, she opts in to import her health data from her previous plan. She also wants to import that historical data, as well as the data her new plan has collected, into her health app.
By processing these requests through a data store, the plan enables the new member to efficiently access the data she wants. The new plan can also use any data the member is willing to share to build a digital engagement experience that offers the following:
The Payer-to-Payer Data Exchange requirements introduce both complexities and opportunities for plans to develop features and services that lead to a richer member experience and competitive differentiation. By using a data store, plans can develop a solution that not only supports compliance but also enables data access capabilities they can build on to exceed members’ expectations, control costs and improve outcomes.