Presenters: Sean McKenna and Dan Sylvia
As healthcare interoperability evolves, health plans find themselves at a critical junction between driving internal business value and meeting increasingly stringent federal regulations. At the InterSystems READY 2026 conference, Sean McKenna and Dan Sylvia detailed how InterSystems enables payers to navigate two lanes: the business/clinical lane and the regulatory lane. While the data sets for both are remarkably similar, the outcomes focus on distinct goals ranging from care coordination efficiency to CMS 0057 compliance.
The Dual Focus for Payers
Payers today must manage a complex portfolio of requirements. On the business and clinical side, the emphasis is on care management, quality/risk assessment, and operational efficiency. This portfolio management involves using data to better coordinate patient care and manage risk pools effectively. Conversely, the regulatory lane is driven by transparency and compliance mandates, specifically around access and interoperability APIs and Electronic Prior Authorization (ePA).
Overcoming Data Challenges
The foundation of any payer strategy is clinical data, which remains notoriously fragmented. Data originates from a variety of sources, including providers, Electronic Medical Records (EMR), and Health Information Exchanges (HIE). This variety leads to significant challenges in data maturity, duplication, and variation in interoperability standards. HealthShare addresses these obstacles through a structured four-step process:
- Data Ingestion: Bringing disparate clinical data into the system.
- Unified Care Record: Consolidating data into a single, comprehensive view.
- Data Activation: Putting the data to work via mechanisms such as FHIR APIs and push notifications.
- Value Outcomes: Realizing improvements in care coordination and regulatory compliance.
Key Value-Add Use Cases
Several high-impact use cases demonstrate the immediate value of Payer Services for payers. Real-time Event Notifications (ADT) allow health plans to receive instant alerts for care management, ensuring that employees can intervene when members are admitted or discharged.
In the realm of quality measurement, HealthShare streamlines HEDIS measures by delivering necessary information to the right personnel in time to meet strict deadlines. Furthermore, the “Chart Chase” or clinical data capture use case replaces manual, labor-intensive processes—like phone calls and faxes—with automated data distribution from the Unified Care Record. This automation directly improves HEDIS and Stars performance while lowering administrative costs.
CMS 0057 and Electronic Prior Authorization (ePA)
The transition from CMS 9915 to CMS 0057 represents a major shift in regulatory expectations. Central to this is ePA 2.0, which facilitates automated prior authorizations. InterSystems is currently implementing ePA 1.0 for customers while preparing for the 2.0 release. The InterSystems Payer Integration Framework acts as a robust broker for this traffic.
The Payer Integration Framework manages request routing, data transformations, and service adapters, allowing payers to ingest different interpretations of standards and call internal APIs to enrich data (such as determining the specific line of business). This framework is essential for handling multiple downstream vendors and routing traffic to the right destinations.
Roadmap and Future Outlook
The roadmap for 2026 includes significant expansions to the Provider Access and Payer-to-Payer APIs. The Payer-to-Payer API will focus on member matching and FHIR-based data exchange between plans, including opt-out capabilities. The Provider Access API will feature attribution lists and opt-in mechanisms.
HealthShare is positioned not just as a database, but as a dynamic engine for making data available across the entire healthcare network. By leveraging tools such as FHIR Gateway and API Manager, health plans can achieve compliance while lowering costs and improving member outcomes.
