A smarter model for payer-provider integration

Why one integration could reshape network performance

Establishing payer-provider integrations has long been a source of operational drag for payer organizations — characterized by piecemeal connections, fragmented data, and care delays. While technology has advanced, the problem hasn’t gone away. In fact, the more distributed the care ecosystem becomes, the more pressing the need for real-time, scalable data exchange.

"Scalable" is the operative word here. Right now, for many healthcare IT platforms, integrating payers with provider organizations can only happen one entity at a time via a single health system, practice, and connection. This approach is resource-intensive and  difficult to maintain.

There’s a better way. By connecting directly to a national, cloud-based provider network, payers can dramatically reduce administrative burden and gain real-time visibility into member activity across systems, specialties, and geographies. At athenahealth, we’ve built a model for this: one integration that connects payers to thousands of  providers in all 50 states, and right inside the workflows  those providers use every day.

This shift drives efficiency, of course, but it’s not just about serving up data more conveniently. It’s about enabling a new level of precision, scale, and coordination across the payer’s core operations and the entire U.S. healthcare ecosystem.

A better way to coordinate care — with immediate impact

Most clinical data exchange today is slow, siloed, or dependent on workarounds. It's a pain, and a drain on resources and relationships.  A direct connection into a nationwide provider network can bring simplicity to a complex process. When relevant member clinical data such as care gaps, diagnosis gaps, ADT events, and in-network referral options are embedded directly in the EHR workflow, the impact can be immediate:

• Reducing practice administrative burden
• Facilitating necessary follow-up care
• Improving high quality care
• Documenting potential and suspected diagnoses
• Reducing cost
• Improving member satisfaction

Instead  of chasing data and sending status through multiple channels, payers can see and address opportunities directly in their clinical workflow at the point of care. This eases the burden on physicians, practices, patients, and payers.

A single integration with national reach

Unlike point solutions or custom interfaces, athenahealth’s model is built to scale. With one integration, a payer can enable real-time data exchange with thousands of providers   on the athenahealth® network — and just like that, individually onboarding practices and negotiating separate technical builds become relics of the past. This means faster time to value, more consistent data flows, and a drastically reduced integration footprint for payer IT teams. It also delivers a more usable experience for busy providers: the data they need is surfaced in the workflows they already know and use.

Just as importantly, this model allows payers to see across athenahealth’s entire network with a single connection, instead of a patchwork of hospital systems and ACOs. For members who receive care in multiple settings (which most do), that cross-network visibility supports more complete risk adjustment, quality performance, and better insight and engagement strategies.

The ability to connect once to a live, nationwide provider network and receive clean, real-time data is no longer a future-state vision. It’s available now.

A smarter foundation for value-based success

Real-time, bidirectional data between payers and providers, surfaced at the point of care,   supports better clinical and member outcomes, as well as payer goals such as:

• HEDIS and Stars performance: Surfacing care gaps  in the clinical workflow in the moment of care can reduce care delays and support providers in closing those gaps, leading to better HEDIS and Stars performance.
• Risk adjustment accuracy: Potential and suspected gaps can be presented and provider actions returned to the payer to support appropriate risk documentation.
• Network referral process improvement: Insights during ordering across provider types and locations helps providers offer high quality, lower cost options that align with the patient’s needs.
• Better care coordination: Appointment and ADT information   not only keeps payers informed about their members' activities, it prompts providers to take necessary actions to keep those members on track with their care plans.

Moving from transactional to strategic

The cost of fragmented infrastructure is real, as reflected by expensive out-of-network referrals, missed opportunities to close gaps in care, and member frustration. But the larger cost is strategic. Payers that continue to rely on reactive, fragmented data flows may struggle to scale value-based programs, manage risk, or deliver on member experience expectations.

What does it look like when payer-provider integration is the norm? Take medical prior  authorization as one great example of what's possible. In the current state, providers and members are frustrated by what is often a cumbersome and time-consuming process for each authorization needed. But with Electronic Prior Authorization, athenaPayer® enables a direct connection to the payer, following Da Vinci standards. This allows us to surface authorization requirements right in the clinical workflow, reducing this burden so clinicians can focus on their patients.

The ability to connect once to a live, nationwide provider network and receive clean, real-time data is no longer a future-state vision. It’s available now, and payers that adopt it are seeing measurable gains. As care continues to move across settings, systems, and digital platforms, the organizations best equipped to manage that complexity will be those who invest in simple, scalable infrastructure that makes data work in real time.

The network is there. The data is ready. The only question is how quickly payers are prepared to connect.

Learn more about athenaPayer and how payers can have direct integration with athenahealth’s national network.