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Beyond Compliance for Payers: A Unique Opportunity

Associate Vice President Healthcare Strategy

The 21st Century Cures Act mandated all health plans to publish a public API to provide members’ access to their data by July 1, 2021 in order to stay in compliance. This regulation has created the opportunity for an unprecedented exchange of healthcare data, breaking the silos that had limited transparency in members’ healthcare journeys. These new data sources present a unique opportunity for health plans to accelerate access to insights, prevent acute events, improve quality, and ensure appropriate services are provided to their members.

Now is the time for health plans to start to think beyond compliance: How can you use this newly available data to support and improve critical business functions?

We will explore several use cases that can put this data to work to provide better outcomes for members and health plans:

Avoid Gaps in Care During Enrollment

Member enrollment introduces many challenges when members switch to a new plan. Plans currently lack comprehensive information on incoming members, resulting in potentially disruptive onboarding. Issues such as gaps in continuity of care, prescription refills, out-of-network risks, and missed authorizations can potentially be avoided by integrating “patient access” data into the enrollment workflow.

Improve Star Ratings and Increase Reimbursement

Quality measures and identifying gaps in care are an essential part of any health plan’s operations. Not only do they improve patient outcomes, but they can increase reimbursement and Star ratings. Integrating United States Core Data for Interoperability (USCDI) and claims data into a member’s profile can help to identify these gaps and ensure that the measures are met going forward.

Develop a Holistic Member Profile Across Health Plans

Coordination of benefits between plans is a challenge that all payers face —ensuring that members receive comprehensive but non-duplicative care is paramount to managing outcomes and cost. By using the SMART on FHIR data standard for interoperability, payers can request data on a member’s behalf from other plans to develop a holistic profile and manage care appropriately.

Maintain Compliance with a Trusted Data Partner

These are just a few of the potential use cases available as we move into the next generation of interoperability. There is a multitude of member insights that can be gleaned once this data begins flowing.

LexisNexis® Risk Solutions has a long history of data management, normalization, enrichment and providing insights to our customers. We believe there is a huge opportunity to optimize this data for the benefit of payers and their members. That is why we are building a solution that can connect to the newly mandated source of healthcare data. We will connect to the manifold of externally facing “Patient Access” APIs being published and provide a “gold-standard” output to customers in a normalized format.

Additionally, we can enrich this data with value-added LexisNexis Risk Solutions datasets, such as LexID®, Keep Contact and social determinants of health to provide our customers the most holistic member profile possible. As health plans begin exploring how to use this data to improve their operations, we can provide the data and insights required.

Learn more about the new interoperability rule and the efforts payers much take to stay in compliance with new regulations from the 21st Century Cures Act.

The DNA of Healthcare

At LexisNexis Risk Solutions, our goal is to provide the healthcare industry with insights and innovations to improve outcomes, grow market share, reduce fraud and increase compliance.

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