White Paper: Enhancing Payer-Provider Collaboration with Epic’s Payer Platform

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.

AI-Driven Workflow Automation and Enhanced Clinical Processes

The Epic Payer Platform harnesses the power of artificial intelligence to take automation and efficiency to new heights. By integrating AI capabilities, the platform streamlines prior authorization workflows, allowing provider teams to submit requests directly within their EHR experience and monitor status in real time. This not only reduces administrative overhead, but also expedites the approval process—freeing up staff to spend less time on paperwork and more time engaging with patients.

Beyond automating prior authorizations, AI plays a critical role in refining risk adjustment and clinical documentation. Predictive models help identify care opportunities, inform decision-making, and ensure that crucial patient information is captured and transmitted accurately. These enhancements enable payers and providers to close care gaps more effectively, coordinate next steps faster, and ultimately support more timely patient care.

As AI-driven features continue to evolve, users can expect ongoing improvements in efficiency, accuracy, and the ability to deliver proactive, high-quality care.

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.

Staying Ahead: Monitoring Updates and Enhancements

Healthy collaboration in an evolving healthcare landscape demands access to the latest technology enhancements. Fortunately, keeping current with Epic Payer Platform updates is both straightforward and essential for maximizing your return on investment.

Here are some best practices for staying up to date:

• Reference the Platform Roadmap Epic regularly publishes a detailed roadmap outlining upcoming features, improvements, and compliance updates—especially for areas like HEDIS® measures, risk adjustment automation, and prior authorization processes. Reviewing this roadmap ensures your teams are aware of what’s on the horizon.

• Subscribe to Release Notes and AlertsEnsure key stakeholders within your organization are subscribed to Epic’s release communications. These updates often highlight critical enhancements, process automations, and new analytics options, providing the information you need to prepare and adapt.

• Engage with User CommunitiesParticipating in relevant Epic user groups, regional consortiums, or online forums facilitates knowledge sharing. Collaboration with peers means you’ll hear about best practices, troubleshooting tips, and practical lessons from early adopters.

• Leverage Vendor Support and TrainingTake advantage of any vendor-led webinars, training sessions, or implementation workshops to ensure your staff stays at the forefront of the platform’s capabilities. Ongoing training is crucial, especially as new features roll out that impact compliance and operational efficiency.

By proactively staying informed and engaged, organizations can fully leverage the platform’s enhancements—continuously strengthening care quality, operational outcomes, and patient satisfaction.

What’s Next for the Epic Payer Platform?

Looking ahead, several enhancements are on the horizon that will take the Epic Payer Platform’s capabilities even further. Key areas of focus include:

• Enhanced Quality and HEDIS® Capabilities: Ongoing improvements aim to refine existing tools for quality measurement and reporting. This includes more granular controls over HEDIS® submissions, smarter analytics, and expanded data sharing to support value-based care initiatives.

• Automated Risk Adjustment Submissions: Streamlining risk adjustment processes remains a top priority. Future updates will introduce even greater automation, allowing health plans and providers to reduce manual workloads and keep pace with evolving regulatory requirements.

• Next-Generation Prior Authorization: Building on current successes, the platform will further automate and standardize prior authorization workflows. These enhancements are poised to improve response times, minimize administrative processing, and increase transparency between payers and providers.

• Better Roadmap Visibility: Platform users will have access to regular updates and feature previews through ongoing roadmap communication. Staying engaged with these updates will help organizations capitalize on new tools as they launch.

By continuing to invest in automation, data exchange, and interoperability, the Epic Payer Platform positions organizations to adapt swiftly and confidently in a rapidly evolving healthcare landscape.

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.