Insuring the future with a payer-provider partnership

New technologies and regulations make collaboration more valuable than ever

In brief:

• New technologies and regulations are changing the healthcare landscape.
• For proactive health payers, these changes carry immense opportunity.
• By partnering with providers and leveraging new technologies, healthcare payers can unlock new value.

New technologies and evolving regulations present opportunities for healthcare payers, and also highlight the need for closer collaboration with providers. Many of the current challenges in healthcare – including simple and transparent payments, consistent quality of care, and data standardization – could be improved if payers and providers had access to the same information. Recently, the Healthcare Financial Management Association (HFMA) cited collaboration between payers and providers as essential. By reducing administrative friction and breaking down information silos, payers and providers can reap the full benefit of the changing healthcare landscape, and further their common goal of delivering high quality care to patients.

Here are four key technological and regulatory changes, and the value that could be gleaned from closer collaboration between insurers and providers:

1. Technology advancements create valuable patient data and personalized care

Advancements in technology such as electronic health records (EHR), wearable devices, and remote patient monitoring (RPM) are expanding the capabilities of personalized care. These are giving rise to new innovations such as Google AI tools that offer a non-invasive, scalable, and cost-effective way to predict cardiovascular risks using retina scans. This enables early detection, personalized treatment, and broader access to care. Current barriers to reaching patients earlier can be overcome by sharing the data responsibly these new technologies produce, in compliance with data and privacy regulations. This will enable payers to collaborate with providers to play an active part in early detection, better define insurance plans, process payments more quickly, and deliver better care earlier before issues progress.

2. Generative AI enables efficiencies for payers and providers alike

Generative AI (Gen AI) has opened a new frontier helping payers automate claims, assess risks, personalize coverage, and support members through chatbots and virtual assistants. For providers, Gen AI is being used in various areas, including supporting clinical decisions, automating routine administrative tasks, and educating patients.

Gen AI has started helping both payers and providers reduce operational costs, streamline processes, and bring efficiencies. However, for members to fully benefit from these innovations, challenges like system integration, data privacy, and security must be addressed. Investments in new technologies can break down data silos and improve information sharing between payers and providers.

3. Changes in Medicare Advantage (MA) create opportunities

Although current enrollments are concentrated between two MA providers with a combined share of 47%, there may be an opportunity for smaller payers to bite off a bigger share of the market. A report from the Kaiser Family Foundation found that 40% of MA beneficiaries underutilized their benefits in 2023. Payers that encouraged customers to better take advantage of those benefits could be rewarded with growth. Also, the pie is growing for all payers. The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage (MA) plans will rise from 54% to 64% by 2034.

Considering these developments, MA plan providers are revisiting their strategies to take advantage of this potential growth. This will ensure improved benefit design and transparency with respect to sharing data with CMS.

4. Regulations for coverage transparency and authorization wait times

In 2024, the health payer industry will undergo significant regulatory changes, focusing on price transparency. Healthcare payers are at various stages of adopting the Transparency in Coverage Rule and the No Surprises Act, both of which are central to these transparency efforts.

The Medicare Advantage and Part D Final Rule will introduce policy updates affecting marketing, prior authorization, and network adequacy. Payers must also adapt to the CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule, which emphasizes the integration of system functions and coordination across the healthcare ecosystem. These rules address weaknesses in prior authorization processes by:

• Requiring payers to issue decisions within 72 hours for expedited requests, and seven days for standard requests to reduce urgent care wait times, starting in 2026.
• Mandating adoption of HL7 Fast Healthcare Interoperability Resources (FHIR) Prior Authorization API, which will automate authorizations, therefore boosting efficiency.
• Requiring payers to publicly report prior authorization metrics, including denial rates and reasons.
• Requiring payers to upgrade their patient access API to include prior authorization data and implement a provider access API by January 2027.

This will streamline, automate, and bring transparency to the prior authorization process, dramatically reducing patient wait times.

Payers should go beyond the mandate and embrace interoperability

The CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule should not be limited to prior authorization only. The healthcare payer of tomorrow should treat this as a step towards enhancing the interoperability of healthcare data across systems, improving the transparency and efficiency of all processes, and ultimately ensuring better coordination of care.

The FHIR standard enhances healthcare data exchange and integration, and while most healthcare payers have taken steps towards adopting it, few are benefitting fully. To gain the most value from interoperability will require:

• Embracing cloud-based solutions for scalability and real-time access
• Standards compliance and governance
• Implementing patient-centric interoperability through APIs.

New technologies are worth the investment

For healthcare payers that keep pace with new technologies, these changes represent an opportunity. To support API-based secure data exchange and governance, payers will need to update core administrative systems. Investments in integrated data analytics, predictive modeling solutions, and Gen AI are also crucial for delivering accurate, personalized, real-time information to members.

The health payer ecosystem must be modular to allow for flexible data sharing with external entities, including information about plans, pricing, coverage, members and compliance, as well as analytics derived from the same. Establishing standards, robust auditing, rigorous testing, and regular monitoring is essential for seamless data exchange and governance.

There’s work for providers too. By implementing EHR and interoperability solutions, providers will improve clinical workflows, enhance personalized care plans, and improve patient engagement, ultimately resulting in superior service delivery and coverage.

By focusing on these measures, payers and providers can drive operational excellence, creating a more efficient, responsive, and cost-effective healthcare system.

“We will explore in detail how leveraging digital tools, data analytics, and AI can deliver operational excellence in the health insurer’s complex provider management space. Join us in in the next chapter for understanding how regulatory changes, value-based benefit plans and industry changes will impact your future organizational goals and creating a proactive roadmap. Stay tuned for our next blog.”