CMS’ interoperability rule will require many insurers to have application programming interface capabilities by Jan. 1, 2027. The clock is ticking, but some health plans are ahead of the curve.
CMS is seeking patient access, provider access, provider directory, payer-to-payer and prior authorization APIs. Epic has been working with many payers toward the prior authorization objective, with 16 payers in testing, as of Epic’s Aug. 17 news release.
However, UnitedHealthcare, Network Health and Aetna have already gone live with Epic’s API. Network Health’s parent organization, Froedtert ThedaCare Health in Menomonee Falls, Wis., as well as Ochsner Health in New Orleans, Denver Health and Summit Health in New Providence, N.J., have signed onto real-time prior authorization checks.
Becker’s spoke with Network Health President and CEO Coreen Dicus-Johnson about how the insurer beat the clock.
Network Health has been working with Epic on several APIs, beyond just prior authorization, to cover its bases ahead of 2027. The prior authorization API, in particular, aims to automate how providers learn about prior authorization and the required documentation, as well as to assist with the exchange of requests and decisions.
Ms. Dicus-Johnson said this is her third time deploying Epic as a leader.
“One of the things I love about Epic: the good install model, the precision. It’s very well thought out. They’re a very good partner,” she said, adding how these kinds of installations can often feel “overwhelming.”
She said Network Health has been focused on “taking administrative burden, and emotional burden that comes with the administration burden, out of the equation.”
“We felt like being an early adopter would help us do that, especially with our owners, so that we can get the bugs out, make sure we’re designing processes and such that really are patient, member centric,” Ms. Dicus-Johnson said.
When asked whether provider-sponsored plans could be uniquely positioned for these interoperability and prior authorization requirements, she said that is true “to the extent that they’re willing to experiment and try new things together.”
In terms of measuring success with the prior authorization platform, Ms. Dicus-Johnson said Network Health is reviewing the percentage of prior authorizations that are electronic. Her team will gather insights on the difference between manual and expeditious processes and how other providers are connecting with APIs and getting access.
“We’re using this as a platform for us, our continued growth, to have less reliance on human resources, so that we can scale at a faster pace,” she said. “All of those things are being factored in because we are bringing that into our analysis for a return on the investment that we made, as well.”
About 50 payers previously pledged that at least 80% of electronic approvals will be handled in real time by 2027. While Ms. Dicus-Johnson could not definitively give a percentage goal for Network Health, she said the goal should eventually be 100%.
“The timing of that will depend on all the workflows and the information,” she said.
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