Improving Healthcare Data Sharing Between Providers and Payers

Healthcare data powers nearly every aspect of provider operations, from treatment decisions and care coordination on the clinical side to revenue cycle management and claim submissions for billing and revenue generation. Without healthcare data sharing mechanisms and payer-provider collaboration, we can’t improve patient care quality or control costs at individual or population health levels. 

What data flows through these essential healthcare data-sharing channels and how do they work? Read on to learn more.

What is healthcare data sharing?

Healthcare data sharing refers to the information exchange among patients, providers, and payers for numerous types of data:

  • Provider data: Enrolling providers in health plans requires sharing providers’ demographic, credentialing, and other data with payers, and updating that information promptly when it changes.
  • Clinical data: Clinical data includes information and results related to an individual’s care including medical records, vital signs, medications and immunizations, imaging data, scans, questionnaires, encounter notes, and orders. Providers use clinical data to make treatment decisions, submit medical claims, track and improve outcomes, and manage population health. Anonymized, it may be used for clinical trials. Payers access clinical data to determine medical necessity, provide prior authorizations for services, and identify social determinants of health (SDoH), the societal or life-related factors—such as income, access to transportation, and food insecurity—that affect a person's health.
  • Administrative data: Administrative data includes enrollment information, eligibility data, claims, and managed care encounters. Health plans use administrative data to oversee payment for care, monitor utilization, manage populations, and better understand resource use and needs of specific patient populations. Payers’ claims and health information give providers a complete view of patients’ health issues and provider interactions. Analyzing administrative data allows health plans and providers to:
    • Gain insights about diagnoses, treatments, and billed and paid amounts
    • Interpret costs
    • Track utilization and treatment
    • Track medication refill patterns and changes in medications

What are the benefits of sharing healthcare data between payers and providers? 

Health systems and insurance companies operate as business partners with occasional opposing goals, which requires strategic decision making when it comes to data sharing. It’s clear that payers and providers must work together to determine which party is best equipped to perform each function on the journey to provide quality care while containing costs. Sharing healthcare information benefits both parties to:

Increase administrative efficiency

Determining medical eligibility is a cumbersome process that typically requires the provider to contact the payer (often by phone). Although most electronic health records (EHRs) can identify patients’ current insurance status, EHRs don’t include information about the precise amount of coverage and copays at the point of care for specific orders or referrals. Providers often can’t determine whether a diagnostic procedure or treatment is covered or its cost in a patient’s health plan without contacting the payer. Without sharing data, payers cannot use coverage determinations to guide care toward better quality or lower cost options.

Under fee-for-service payment models, healthcare providers needed to submit only simple information (e.g., the names of the tests and procedures) with their claims. However, under value-based contracts, healthcare payers also must know the treatment results to measure the quality of care outcomes. Therefore, providers must submit information such as lab results, admission and discharge information, body mass index, vital signs, and results of screening procedures and preventative health assessments. A study suggests that providers communicate with up to 20 payers per week to accomplish this task. Payer agents sometimes contact a provider repeatedly for the same purpose, distracting physicians from patient care and contributing to clinician burnout. Electronic sharing of clinical data between payers and providers streamlines the claim submission process, eliminating the need for time-consuming back-and-forth communication.

Improve care coordination and patient outcomes—and cut costs

Provider-payer collaboration is important for care coordination. Providers require prompt receipt of information about a patient’s hospital admission from the payer, while there's time for the physician to deliver and coordinate that patient’s care. For example, when a physician doesn't know their patient was admitted to the hospital, they cannot provide follow-up care that prevents readmission. The patient may have already received expensive care from an orthopedist for a sprained ankle that, for example, could’ve been treated by the primary care physician. Likewise, when payers have access to patient medical records, clinical decision making (via determination of medical necessity and prior authorization) is expedited, so patients receive the care they need, thereby improving outcomes.

Healthcare data sharing between providers and payers may also impact coverage decisions and costs of care. For example, a health insurance plan may cover the cost of one or two inhalers per month for an asthmatic child. Two inhalers may not be enough, however, when an extra needs to be left at school or kept on-hand for trips. Without extra inhalers, the child may wind up in the emergency room or an after-hours clinic. But when the payer has access to encounter notes and other medical records, they know what caused the episode that resulted in an ER visit—the child lost his inhaler and didn’t have a back-up inhaler at school. 

Accessing and analyzing the child’s clinical data allows the payer to see problematic patterns and approve more inhalers. When payers and providers work together to proactively and holistically provide healthcare services, the cost to the payer and the parents (in this case for additional inhalers) is lower than the cost of ER visits. Data sharing between providers and payers increases care coordination that can reduce ER visits, hospital admissions, medication errors, and duplicate tests—in the end decreasing healthcare costs. 

Enable value-based care

Healthcare data sharing is essential to improve care quality and cost efficiency—two tenets of value-based healthcare. Providers need visibility into all services and care a patient has received to avoid unnecessary (and expensive) duplication. Payers require transparency across care venues to monitor adherence to protocols and enhance plan design. “If the physicians and care teams don’t know their quality scores, or they don’t know if they’re actually getting the right patients in for care, or they don’t know that their patients have actually been hospitalized or in the ER, then they’re not going to be able to appropriately manage the outcome that we negotiate in our contracts,” said Jamie Reedy, MD, MPH, chief of population health for Summit Health.

How do providers share healthcare data with payers now? 

Healthcare data sharing remains largely paper-driven, with providers and payers using fax machines or even snail mail to send documents.

Regarding applications:

  • A 2019 survey of 200 healthcare professionals found that 89% of healthcare organizations still use fax machines. Notably, faxes may jeopardize patient safety (via medical errors) and patient privacy, and patient records being sent to the wrong fax number result in data breaches that violate the Health Insurance Portability and Accountability Act (HIPAA).
  • Although electronic payer enrollment applications are available, many healthcare organizations still submit paper applications via the mail. 

Regarding claims:

  • Electronic submission is now the norm, but attachments—the clinical and other supporting data and documentation submitted to payers—often are exchanged via phone calls, paper pushing, and fax machines. Some providers and payers, however, still use PDF email attachments or manually upload digital documents to online portals.
  • As of 2017, only 6% of the 100 million medical attachments submitted annually were sent electronically. 

Although there has been improvement, the industry lags behind other fields that have embraced electronic communications. As long as manual data exchanges exist, the healthcare industry will face the risk of errors, privacy violations, and delays across the processes of provider enrollment, prior authorization, and referrals, thereby delaying patient care. 

What are the obstacles to data sharing between providers and payers? 

Some healthcare and payer organization leaders are reluctant to share data due to concerns about data security, patient privacy, and fear of giving up a competitive edge. In fee-for-service payment models, providers and payers often viewed each other as adversaries, leading to an us-versus-them mentality. In an arrangement where one party provides the service and the other pays for it, providers will try to influence the prices to rise while payers try to reduce them. 

Under value-based care payment models, providers and payers, whether commercial or federal government insurers, must work together to improve care quality and reduce costs. They must discover ways to overcome perceived and real challenges to data sharing.  

Data security

Every opportunity to share health data carries the risk of having a patient’s protected health information (PHI) stolen by an unscrupulous hacker. From January 1 to July 31, 2021, there were 2,084 ransomware complaints, a 62% increase year over year, and more than $16.8 million in losses, a 20% increase from the previous year. In general, healthcare data breaches are on the rise, according to the 2021 Identity Breach Report

Compared with 2019, healthcare experienced a 51% increase in the total volume of records exposed. After an email account of an employee at a Utah-based physician group was breached in June, about 12,000 medical records were exposed. Medical record numbers, birth dates, procedures, and provider and insurance provider names were all exposed, although they were not shared online.

Sharing information—about what happened to cause a data breach, how it was discovered, the severity of the loss, and what damage resulted from it—may help prevent healthcare cyber attacks by giving other organizations a heads up. Meanwhile, provider and payer organizations need to use health information technology that ensures secure data sharing.

Patient privacy concerns

Providers may avoid sharing health data due to fear of violating the Health Insurance Portability and Accountability Act (HIPAA), which prevents sensitive patient health information from being disclosed without the patient’s consent or knowledge. Obtaining patients’ consent to share their PHI is a technical challenge (i.e., how are we going to do it?) as well as a policy problem (i.e., when do we need to do it?).

Although providers and payers may use it as a reason to avoid sharing data, HIPAA was actually intended to facilitate safe and secure sharing of information. Healthcare providers and health plans are permitted to use and disclose PHI without the individual’s authorization for treatment, payment, and healthcare operations. HIPAA also allows healthcare organizations to share PHI to develop clinical guidelines, improve outcomes for certain populations, or develop protocols.

In December 2020, the Department of Health and Human Services issued proposed regulations modifying HIPAA to guarantee patients the right to request that their providers share data with health plans, and vice versa. The proposed HIPAA modification is a small but first mandate on providers to share data with plans.   

Data inaccuracy 

Patient and provider data come from many sources and are often stored in multiple, siloed systems and departments throughout healthcare organizations, making access and sharing difficult. When the same data is entered several times in different systems (e.g., EHRs and billing software), there's also a greater risk of errors. 

Providers and payers rely on current, accurate patient data to verify patient identities, determine socioeconomic risks, identify affordability gaps, reduce uncompensated care, and improve outcomes. A survey of 100 leaders at payer organizations and 100 leaders at provider organizations revealed that only 37% of payers and 58% of providers are confident that their member/patient demographic information is correct.

Current, accurate provider data is essential for accurate provider directories and compliance with Centers for Medicare and Medicaid Services (CMS) and other governing bodies and regulations. CMS’ review of the online provider directories of 52 Medicare Advantage Organizations (including 5,602 providers at 10,504 locations) found that 50% of the providers had at least one inaccuracy: the provider wasn’t at the location listed, the phone number was incorrect, or the provider wasn’t accepting new patients as indicated in the directory. CMS issued compliance actions (notices of non-compliance and warning letters) based on the results of provider directory reviews.

Interoperability is key to data sharing

Efficiently sharing health data requires system interoperability—the ability of two or more systems to exchange health information and present it so a user understands the data and can use it in their treatment and operations decisions. Interoperability relies on application programming interfaces (APIs)—software intermediaries that allow applications to exchange data and functionality easily and securely. Blockchain is an example of a technology that uses APIs to help overcome varying data standards that reduce interoperability.

CMS has instituted and proposed regulations requiring interoperability to improve access to health information for public health reasons and individuals’ access. Building on the CMS Interoperability and Patient Access final rule (CMS- 9115-F), the Interoperability and Prior Authorization proposed rule (CMS-9123-P) emphasizes the need to improve health information exchange to achieve appropriate and necessary access to complete health records for patients, health providers, and payers.

This proposed rule would require payers to implement APIs to improve electronic sharing of healthcare data between payer and provider, or between two payers, to improve care coordination. Providers must be able to access patients’ healthcare information from payers using their health information exchange (HIE) solution. A new API would make individual claims and clinical data maintained by the health plan available to providers on demand. Under the proposed rule, providers will have to send the entire patient medical record to a patient’s current health plan because that health plan is responsible for transferring the data to the patient’s next health plan.

The Interoperability and Prior Authorization proposed rule also focuses on automating and standardizing the prior authorization process. Providers would access a prior authorization API to send requests for prior authorizations and receive payer responses in their existing workflows. 

Provider data management solutions

Provider data management software allows internal and external data to work together. APIs allow a healthcare organization’s provider management system to access data from external sources such as health plans. By connecting provider lifecycle data (e.g., credentialing, privileging, enrollment, performance improvement, EHRs, claims, and directory information), provider data management software maintains a single source of truth.

In addition, provider data solutions access internal or external ICD-10 and CPT code databases, offer quick-lookup internal privileging status, and connect to patient records while simultaneously managing external information like exclusion databases, licensure, and payer data. This integration eliminates duplicate data entry, saving time and increasing data accuracy.

symplr’s provider data management solutions help healthcare organizations navigate the complexities of provider and payer data management—the first step in sharing that data for mutual benefit.

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