Direct integration and why payers should prioritize it

How real-time data exchange with 170K+ providers drives payer performance and reduces friction

For payers seeking greater efficiency, better data, and more meaningful provider collaboration, the barrier to payer-provider data exchange is often integration itself. The process can be challenging in a number of ways. In some cases, connecting with provider organizations requires individual interfaces — one at a time, practice by practice. It’s slow, resource-intensive, and impossible to scale across a diverse national footprint. In other cases, such as electronic revenue cycle transactions, clearinghouses serve as intermediaries between practices and payers, introducing another step in the process. Similarly, qualified registries often act as intermediaries between practices and value-based care program adjudicators. These extra steps can slow the transfer of data and potentially open the door to breakdowns in formatting, acceptance, and/or processing.

athenahealth offers a fundamentally different model. Through one connection, payers gain access to a nationwide network of more than 170,000 providers¹ across all 50 states. No piecemeal onboarding. No duplicate builds. No intermediaries. Just a direct, secure integration into the EHR and practice management systems already used by clinicians and care teams across the country.

Beyond streamlined access, this model provides real-time, cross-network visibility into provider data — empowering payers to resolve claims issues earlier, identify care and diagnosis gaps faster, and support members more effectively at every stage of care.

Why traditional connections fall short

Despite decades of digital investment, most payer-provider data exchange is still managed through fragmented channels. Clinicians log in to portals, make calls to verify benefits, or work from outdated plan documents. Batch file transfers and manual updates create delays and open the door to avoidable errors.

The downstream effects on payers are clear:

• Administrative costs rise due to rework, appeals, and call volume
• Denials increase from eligibility and authorization mismatches
• Quality performance suffers as care is delayed or disrupted
• Member experience declines due to billing confusion and poor coordination

Without integrated access to the data providers rely on, payers are left to react after issues have already occurred.

What direct integration makes possible

athenahealth’s connected infrastructure changes that dynamic. Through a single, direct integration, health plans can deliver structured, real-time eligibility and benefit data directly into provider workflows — before care is delivered and before claims are generated.

Direct integration enables a significant improvement in payer operations and outcomes, such as:

• Cleaner claims at first submission: Coverage details, network rules, and preauthorization requirements are visible to clinicians during check-in — reducing rejections and minimizing delays.
• Lower administrative burden: With accurate health plan data embedded at the point of care, fewer claims need corrections, fewer calls are made to resolve disputes, and fewer resources are spent chasing retroactive fixes.
• Improved member experience: Members are less likely to receive surprise bills, face care delays, or dispute financial responsibility — leading to higher satisfaction and fewer grievances.
• Cross-network data visibility: By accessing consistent, real-time data from providers across systems and geographies —not just within closed networks or isolated partnerships — payers gain broader intelligence, stronger care management, and deeper insight into each member’s experience.
• Foundation for value-based performance: Eligibility accuracy drives attribution, risk adjustment accuracy, and quality gap closure — enabling payers and providers to perform better in Stars, HEDIS, and alternative payment models.

The ability to connect once and reach over 170,000 providers nationwide creates significant value for payers.

Comparing two paths: with and without direct integration

A scalable foundation for better payer performance

Payers need more than simple system-to-system connections. They need data that is timely, structured, and immediately actionable. Direct integration with athenahealth delivers that, without the operational complexity of managing dozens (or hundreds) of separate provider interfaces.

The ability to connect once and reach over 170,000 providers nationwide creates significant value:

• Reduces overhead and support costs
• Improves speed and accuracy in eligibility and billing
• Enhances the provider experience by removing friction
• Supports member satisfaction and retention through transparency into benefits and responsibilities
• Provides infrastructure to scale quality, risk, and care coordination programs
• Allows payers to approach clinicians using athenaOne® with consistent processes

As healthcare becomes more distributed and performance-driven, payers that enable direct, cross-network data exchange will lead on cost, outcomes, and experience. Integration with athenahealth offers a proven, scalable path to that advantage.

Learn how this integration model can support your strategy. Get to know athenaPayer® or contact our payer partnerships team.