Our guests are Amanda Clifton, Vice President, Technology Solutions, Automation and Core Workflow and Jeffrey Bostelman, Staff VP Interoperability, Clinical Strategy & Architecture, at Centene Corporation.

In this episode, Amanda and Jeff explore the opportunities and challenges of payer-to-payer data exchange and price transparency regulations.

On January 17, of this year, the Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Final Rule, a significant step towards improving member data exchange and delivering holistic care experiences.

With the January 1, 2027, mandatory enforcement date approaching, failure to take proactive steps could result in substantial penalties and connectivity delays. This underscores the urgent need for health plans to act swiftly and decisively to address the challenges and hurdles in establishing secure connections with other health plans.

Price transparency is a series of national policies designed to create a patient-driven healthcare system by making health plans and hospitals in the U.S. more transparent, so patients can better understand what they will pay for goods and services.

Consumerism is built on the tenet that patients have full access to cost and pricing information to make decisions about their health, and these new laws are likely just the start of a series of regulatory initiatives designed to mandate pricing transparency. 

Thoughts? Guest suggestions? Email us at [email protected]

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich & Derrick Nevado.

Learn More

• Availity’s Interoperability Solutions Payer-to-Payer Hub and Prior Authorization Requirements, Documentation, and Decision (PARDD). This webinardelivers an overview of Availity’s approach to two mandates in the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P), also referred to as Interop 3.

Prior authorizations, a critical tool of utilization management, are necessary for establishing checks and balances in the healthcare system. Unfortunately, too many providers and health plans consider the prior authorization process, which relies heavily on manual interventions and analog technologies, burdensome and a potential impediment to timely patient care.

The complexities of prior authorizations make automation and the application of artificial intelligence difficult for several reasons, including:

• Every health plan has its own policies and processes for prior authorizations, which can vary by procedure, provider, and even patient.
• Healthcare’s inconsistent data standards challenges provider integration and automation across multiple health plans.
• The clinical data from the longitudinal patient record required for medical necessity review are trapped in different information silos.
• Patient variability, based on such factors as age, disease states, treatment response, and comorbidities, creates complexity in determining whether an individual meets the medical necessity criteria and poses the most significant challenge to the prior authorization process.

With so much abrasion associated with this transactions, this is an essential conversation to understand how providers and health plans can work more effectively collaborate to facilitate prior authorizations ar speed and scale.

Additional Content

Learn more how Availity is applying artificial intelligence to increase the speed and accuracy of prior authorizations HERE.

Learn more about Availity’s approach to artificial intelligence HERE.

Thoughts? Guest suggestions? Email us at [email protected]

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich, and Derrick Nevado.

Pankaj Jain is Vice President at Highmark Health. Pankaj leads the enterprise Product Realization Office with the mandate for value effectuation of all medical insurance and technology products. Pankaj is at the forefront of promoting digital health and value-based care through various global research endeavors, conferences, virtual events, and by leading enterprise transformations at Highmark that improve healthcare delivery for providers, payers, and consumers. Prior to foraying into healthcare, he led global businesses for Siemens, Rockwell, and GE.

In this episode, Pankaj talks about innovation and change management. In the ever-evolving landscape of healthcare IT, innovation and change management play pivotal roles in shaping the future of patient care. The opportunities that arise from embracing cutting-edge technologies are immense, promising enhanced efficiency, streamlined processes, and ultimately, improved health outcomes. From artificial intelligence optimizing clinical and administrative processes to the seamless integration of electronic health records, the potential for positive change is boundless.

However, with great potential comes great responsibility. Navigating the delicate balance of innovation in health IT presents a unique set of challenges. In a realm where patient lives hang in the balance, precision and reliability are paramount. Ensuring the seamless adoption of new technologies while maintaining the highest standards of safety and privacy demands a strategic approach.

We discuss strategic approaches to innovation and mental models for devising clear goals and outcomes among diverse stakeholders. 

Thoughts? Guest suggestions? Email us at [email protected]

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich, Derrick Nevado, and Alexis Valladares.

Innovation and transformation are top priorities for growth-oriented healthcare organizations. But meaningful and sustainable transformation presents and extraordinary challenge. Departmental silos, complex bureaucracies, and organizational inertia often prevent good ideas from every showing up on a solutions roadmap.

My guests Jesson Zafar and Dennis Kramer of Sentara Health Plans have spent the past couple of years thinking of little else than the lifecycle of solution development—from ideation to go-to-market and everything in between. Together, Jesson and Dennis have created a system for nurturing ideas from across the enterprise.

We hope this enlightening conversation will give you some ideas on how to scale and implement your own Transformation Center. Jesson and Dennis discuss how they created Sentara’s Transformation Center, how it works in practice, and how they have engineered their process to ensure that good ideas, regardless of where they come from within the organization, are given a chance to reach their full potential.

Thoughts? Guest suggestions? Email us at [email protected]

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich, Derrick Nevado, and Alexis Valladares