Introduction
In an era of value-based care and increasing healthcare complexity, payers and providers must collaborate efficiently to improve health outcomes while reducing administrative burdens. Epic’s Payer Platform for Payers is a nationwide network that enables seamless bidirectional data exchange, automating workflows and ensuring a comprehensive view of patient health records.
This white paper explores how the Payer Platform fosters improved care coordination, quality measurement, and administrative efficiency, ultimately leading to better member outcomes and cost savings.
Challenges in Payer-Provider Collaboration
Despite the push towards interoperability and value-based care, healthcare organizations face significant barriers:
1. Fragmented Data Exchange – Providers and payers often rely on manual communication (phone calls, faxes, and emails) to share critical patient data.
2. Care Gaps and Delayed Diagnoses – Lack of real-time insights leads to unnecessary tests, duplicated services, and incomplete patient records.
3. Administrative Inefficiencies – Prior authorization processes and claim adjudications are often time-consuming, leading to delayed care.
4. Quality Reporting Challenges – Accurate HEDIS® measure tracking and risk adjustment require extensive data collection, often requiring manual chart retrieval.
The Epic Payer Platform directly addresses these challenges by creating a centralized network for real-time data exchange, improving both administrative efficiency and clinical outcomes.
The Epic Payer Platform: Transforming Data Exchange
The Epic Payer Platform integrates payers, providers, and healthcare organizations into a single interoperable network, ensuring real-time, structured data exchange across multiple stakeholders.
Key Features and Benefits
1. Seamless Data Exchange for Value-Based Care
· Standardized Epic formatting ensures smooth integration across organizations.
· Clinical Data Exchange (CDE) provides real-time diagnostic, lab, and treatment updates as soon as a provider completes an encounter.
· Supports proactive risk adjustment and care gap closure, improving HEDIS® scores.
2. Improved Quality Measures and HEDIS® Compliance
· Clinical Analytics Document (CAnD) facilitates automated clinical data exchange.
· Payers can request specific data over defined lookback periods (e.g., 10 years) for accurate HEDIS® measure calculations.
· Reduces manual chart retrieval, ensuring efficient compliance tracking.
3. Social Drivers of Health (SDoH) Integration
· Aggregates social risk factors (e.g., housing instability, food insecurity, transportation access).
· Helps care managers tailor interventions based on real-time patient needs.
· Enables cross-organization visibility into SDoH trends, ensuring holistic patient care.
4. Preventative Care and Chronic Condition Management
· Avoids unnecessary tests by marking fulfilled care gaps in real-time.
· Providers access a deduplicated patient health record via Happy Together.
· Enhances risk adjustment accuracy by identifying missing diagnoses and HCC coding.
5. Coordinated Care Management Across Organizations
· Tracks member enrollment in care management programs across organizations.
· Allows care managers to coordinate outreach and interventions effectively.
Reducing Administrative Burden in Revenue Cycle Management
Prior Authorization Automation and Compliance
· Real-time authorization requirements visibility to providers.
· Meets Da Vinci Coverage Requirements Discovery standards for CMS Interoperability and Prior Authorization compliance.
· Instant authorization decisions for 53% of Ochsner’s in-scope services (Humana case study).
Accurate Member Coverage and Provider Network Management
· Coverage Finder provides real-time member eligibility and benefits verification.
· Provider Finder helps referring providers identify cost-effective, in-network specialists.
· Automated provider directory updates ensure accurate referral management.
Automated Event Notifications for Enhanced Coordination
· Notifies payers and providers of admissions, discharges, transfers, and scheduled appointments.
· Prevents redundant outreach for already scheduled appointments.
· Ensures timely post-discharge follow-ups.
Advanced Analytics and Member Engagement
Performance Analytics for Process Optimization
· Self-service analytics via SlicerDicer.
· Tracks authorization trends, care quality, and utilization patterns.
· Pre-configured reports for HEDIS®, risk adjustment, and operational efficiency.
Member Engagement and CRM
· MyChart portal consolidates payer and provider data for seamless member access.
· Cheers CRM supports personalized customer service with integrated claims, coverage, and referral data.
· Enables targeted outreach campaigns to improve preventative care participation.
Impact and Adoption
· Over 230 healthcare organizations and the seven largest payers are currently live.
· Supports 150 million covered members.
· Improves efficiency, reduces costs, and enhances patient care coordination.
Case Study: Humana & Ochsner
· 75% of Humana and Ochsner’s care gap closures for the Controlling High Blood Pressure HEDIS® measure were accounted for by Payer Platform.
· 53% of prior authorizations for Ochsner’s services were processed instantly.
Conclusion: A New Standard in Payer-Provider Collaboration
The Epic Payer Platform is a game-changer for payer-provider interoperability. By automating data exchange, improving quality tracking, and streamlining administrative processes, healthcare organizations can achieve better patient outcomes, reduced costs, and improved efficiency.
As the industry continues to shift towards value-based care, investing in interoperable, scalable platforms like Epic’s Payer Platform is essential for long-term success.
Next Steps
For organizations looking to adopt or optimize their use of the Epic Payer Platform:
· Hire experienced contractors from HiPaaS that will perform the following actions:
o Conduct an interoperability assessment.
o Establish governance structures for data sharing.
o Align quality measurement and value-based care initiatives with Epic’s analytics tools.