Being Better Business Partners

Contributing experts: Shane Hochradel and Ninad Umrani

Being better business partners means working in a meaningfully different way. We're dedicated to fostering collaboration and active partnerships with care providers through digital solutions that streamline our interactions, from contracting to payment.

Leveraging Electronic Medical Records and Data Connectivity

By sharing data, aligning care management, and providing automated solutions — such as those for prior authorizations, roster updates, and claims processing — we create efficiencies and streamline workflows for our care provider partners.

Building a digital platform is foundational to create exceptional experiences for care providers and patients. It's why we're focused on simplifying administration and improving data-sharing.

Our interoperability platform, Health OS, connects care providers, payers, and consumers, to enhance the consumer experience, reduce administrative burden, and improve care outcomes. This comprehensive technology platform also provides care gap closure, real-time data, and improved coordination.

Between payer and care provider, we facilitate seamless, timely collaboration and can connect our consumers to functions that support more personalized, proactive care.

Percentage of Our Consumers Included in Our Health OS Data1

  • Medicare %: 2022: 71.48%, 2023: 83.05%
  • Medicaid %: 2022: 47.89%, 2023: 73.08%
  • Commercial %: 2022: 44.15%, 2023: 54.92%

Health OS is connected to health systems' electronic medical records (EMRs), and Health Information Exchanges (HIEs) across the nation, bringing in critical data for value-based care, care coordination, member experience, and more. Leading health systems across the country have connected with HealthOS via Epic Payer Platform. This connectivity helps ensure care providers have the right data, at the right time while reducing administrative burden, so they have more time to focus on what matters most — patient care.

A key element to providing access to meaningful information is establishing strategic connections. Health OS does that by sourcing data from more than 10,000 care providers and 97 large health systems, spanning across all 50 states for over 27.6 million consumers, helping to drive:2

Increase of

12%

in consumer adherence to Healthcare Effectiveness Data and Information Set (HEDIS) measures.

Increase of

15%

in primary care physicians connecting with patients in a timely manner post-discharge to close care gaps and avoid readmissions.

Increase of

25%

in medication adherence for chronic conditions, such as diabetes and hypertension.

47 million+

automated admission, discharge, and transfer (ADT) notifications.

These efficiencies created by the information from Health OS mean that care providers can spend more time with their patients, with better information to improve health outcomes.

Connecting Consumers, Care Providers, and Payers Virtually

We're using technology to unlock time and financial savings for our care provider partners through streamlined and automated administrative processes. Data connectivity also enables visibility into and improved performance on clinical quality metrics.

Virtual Nurse Onsite — Our nurses access care providers' electronic medical records (EMR) directly, in real time, with read-only access, eliminating the need for care providers to gather and share clinical information. This reduces follow-up requests and authorization denials due to lack of information. It also supports discharge planning programs, arming case managers with clinical insights that make them more effective in engaging with patients, with less disruption to care providers.

To date, the care providers with whom we share data via EMR access have experienced a decrease in administrative work, a decrease in denials based on lack of information, and a quicker review turnaround time compared to those whose EMR we cannot access.

Inpatient Reviews Comparing Facilities With EMR Access Versus Those Without EMR Access3

  • Requests for Clinical Information, 64% decrease: No EMR: 11.8%, EMR: 4.3%
  • Denials for Lack of Information, 69% decrease: No EMR: 5.2%, EMR: 1.6%
  • Peer-to-Peer Reviews, 70% decrease: No EMR: 0.2%, EMR: 0.1%
  • Appeals, 85% decrease: No EMR: 0.4%, EMR: 0.1%
  • Turnaround Time (in days), 20% decrease: No EMR: 1.5, EMR: 1.2

January 2023 to December 2023

Access to EMR data is about putting timely and comprehensive clinical information into the hands of our utilization and care management teams to drive faster decision-making and more comprehensive patient interventions.

Epic Payer Platform (EPP) — This platform allows workflow interoperability and simplifies prior authorizations by streamlining the submission process. We receive and use structured EMR clinical data after care providers agree to share it from their instance of Epic. We are on track to connect with care providers via EPP in 300 hospitals by the end of 2024.4 Epic will soon bring to market a solution that will allow us to be the first payer to use EPP for inpatient concurrent review and discharge planning.

Admission, discharge, and transfer (ADT) — Patient ADT information is delivered regularly to care providers in near real-time, offering a view of emergency and inpatient encounters, as well as changes in care setting. ADT data helps determine which patients require care management interventions, allowing us to execute clinical interventions and alert primary care providers when their patients should be scheduled for follow-up care.

ADTs are also used to identify and engage consumers at high risk for chronic disease complications, readmission to inpatient settings, and/or acute events, such as those who:

  • Are high utilizers of hospital care.
  • Visit emergency rooms frequently.
  • Leave hospitals against medical advice.

These interventions address critical quality measures, such as readmission rates and follow-up measures. By conducting them on behalf of care providers, we can help improve health outcomes in support of our shared overall quality scores and value-based care goals.

EMR feeds — Patient encounter data is shared securely via file feeds in a structured cadence, representing a point-in-time view of clinical information. EMR information is then fed into our consumer insights platform, which our Care Management teams access as part of their data-gathering efforts prior to engaging with a consumer.

Digital Request for Additional Information

Manual methods for claims processing, including printing and mailing documentation, can unnecessarily delay payment. There are ways, however, to make that faster and more efficient.

Our Digital Request for Additional Information (Digital RFAI) process significantly speeds up claims processing time and allows our care provider partners to receive payments faster. Initially, we partnered with select care providers to launch Digital RFAI. With their valuable input, we rolled out an improved process to all care providers across all our health plan affiliates' networks.

Digital RFAI helped drive digitally submitted documentation, which as of December 2023, made up 59% of all submissions, up from 43% at the end of 2022.5

Digital RFAI improves the patient experience as well. Previously, requests for additional information initiated an Explanation of Benefits (EOB) showing a claim was not paid, which risked confusing and frustrating our consumers. Digital RFAI triggers a pend status for most claims, allowing care providers to send us the information needed before a claim may be denied. This suppresses the EOB until a decision is made, supporting clarity for consumers.

At the end of 2023, care providers representing approximately 70,000 national provider identifiers used Digital RFAI and benefitted from:6, 7

A 38% decrease in claims impacting aged payments for Commercial fully insured business.

An increase in matching supporting documentation to the appropriate claims, making it accurate 100% of the time.

Faster claims processing and payments for Commercial claims documentation — running at an average of 23 days by November 2023, compared to 133 days two years earlier.

Utilization Management Simplification

Simplifying utilization management (UM) plays a crucial role in how we collaborate with our care provider partners. Feedback from care providers has helped us develop a technology-enabled, multidimensional approach that includes reducing prior authorization (PA) requirements, increasing EMR access for our clinical teams, and automating the clinical review process. Specifically, we're focused on:

Reducing Administrative Burden

According to 94% of care providers, traditionally, PA delays inpatient care and increases administrative burden.8 To that end, we've reduced the PA requirement on more than 1,000 current procedural terminology codes over the last three years.9

The large health systems connected with our affiliated health plans via Epic's Payer Platform are simplifying the PA process through electronic prior authorization.

Care providers who submit through automated, digital means spend half as much time managing authorizations as those who submit manually. We're collaborating with select high-performing, value-based care providers to test alternative models to remove or automate authorization requirements for a subset of outpatient codes.

Optimizing Digital Engagement

EMR access for our health plan affiliates' nurses means an expedited authorization process.

Our nurses have one-on-one relationships with local care provider partners and round with them virtually, giving care providers the opportunity to better focus on the clinical needs of millions of patients.11

Our subsidiaries, Carelon medical benefits management and CarelonRx pharmacy benefit manager, perform PA using care provider-facing portals for outpatient services and medications, featuring real-time approvals with care provider self-attestation. Nearly 90% of prior authorization requests are submitted via the Carelon Medical Benefits Manager.12

Utilizing Artificial Intelligence

By responsibly using artificial intelligence (AI), we can extract, organize, and summarize relevant information from medical records for UM and case management to further automate and streamline the clinical review process.

To accelerate PA decision-making, we created a tool that uses AI to match faxed documentation to the corresponding medical policy criteria. This helps expedite the review and authorization process.

We use AI and automation to speed up approvals, while denials are reviewed and determined by real people with clinical training. These solutions promote opportunities for care providers to practice "at the top of their license" and accelerate diagnosis and treatment. For our consumers, they help hasten the scheduling of needed services and help decrease confusion and frustration.

Roster Automation

Manually completed provider rosters can cause processing delays and additional work for care providers and payers due to the lack of standardization, data fallout, and the need for follow up to gather necessary information. This can lead to outdated provider directories, resulting in patient frustration and delays in care when seeking care providers.

To help create efficiencies, streamline care provider workflows, and make it easier for consumers to find care, we implemented the industry's first artificial intelligence-enabled, digitized solution so care providers can quickly autoload roster information into our data system.

Roster automation through the Availity13 Provider Data Management (PDM) application helps ensure:

  • Claims payments and roster data are processed accurately and faster — from months to days.
  • Consumers find up-to-date information when searching for care providers.
  • Best-in-class compliance with federal and state mandates.

In 2023, we processed more than 81 million roster transactions.14

>81 million roster transactions

Of those, 93% went through the automated process, reducing turnaround time from what has originally taken the industry upwards of 90 days to process each roster to less than four days.

Technology Designed to Improve the Healthcare Experience

See how our digitized roster automation solution cuts down data processing time and helps patients find the care they need faster.

1 Elevance Health, internal reporting (February 2024). 2 Elevance Health, internal reporting (February 2024). 3 Elevance Health, internal reporting (December 2023). 4 Elevance Health, internal analysis (January 2024). 5 Elevance Health, internal reporting (December 2023). 6 Elevance Health, provider digital RFAI progress dashboard (December 2023). 7 Elevance Health, provider digital RFAI process dashboard (December 2023). 8 Beckers Hospital Review: 17 fast facts on prior authorization (April 4, 2023): beckersasc.com. 9 Elevance Health, internal analysis (2023). 10 Elevance Health, internal analysis (December 2023). 11 Elevance Health, internal attribution analysis (September 2023). 12 Carelon, internal data (December 2023). 13 Availity, LLC is an independent company providing administrative support services on behalf of the health plan. 14 Elevance Health, RA Monthly Transaction Volume Report (December 2023).