The Client
A massive pay-vider organization with a staff of over 200,000 personnel, operating more than 30 hospitals and hundreds of clinics that serve millions across the United States.
Problems Faced
The client required a solution that would make them compliant with the CMS-9115-F Rule (Interoperability and Patient Access Final Rule) while enabling flexibility to meet any subsequent regulations. The challenge was integrating a scalable solution across their entire payer-provider network. Their network served ~12.5 million members and generated over 32TB of data annually which needed to be exchanged at high velocity.
Objectives
The client required a compliant enterprise-level solution without compromising security, and without significant down-time. Their key objectives were:
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A FHIR®-native backend that could ingest mega-volume data, a minimum of 1.6 billion claims, from across different systems in a variety of formats.
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A fully integrated implementation of the CMS-9115-F solution across the client’s entire network, within 3 months.
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Implementing on Azure Cloud so they could process as much as 64TB of data by 2025, which was double their 2021 volume.
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Investing in a solution that built upon their data strategy and could be leveraged for other uses, including meeting future regulations.
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Procuring a solution from a vendor they could trust with proven large-scale, real world implementations.
The Solution
The client procured Smile’s Health Data Platform (HDP) to start them on their compliance journey. Their entire network was fully adherent to the CMS-9115-F Rule specifications within their 3-month requirement.
Based on the extensive experience from over 160 FHIR-based enterprise-level implementations, and actively innovating with HAPI FHIR and Da Vinci IGs (Implementation Guides), Smile was able to provide the requisite architecture and upgradable data models to the client that met and surpassed their production requirements and satisfied their most optimistic growth targets. The following features and capabilities of the HDP were key to them achieving all their objectives, and future-proofing their investment for upcoming mandates.
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FHIR-native platform - Smile’s HDP is built upon the widely adopted open healthcare standard, FHIR. This gave the client an intrinsically compatible data exchange infrastructure with no vendor or proprietary system lock-in.
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On-cloud - The HDP is designed to run wherever data is stored—on premises, on cloud, across multiple cloud platforms, or a hybrid setup. The client’s hybrid setup was reconfigured to Azure Cloud as per their direction.
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Performance - The HDP proved its processing capability of 1.6 billion claims across the client’s network, as per their requirement. Since then, the processing power of Smile’s HDP has grown to a ground-breaking 255,087 transactions per second, returning search queries across the network in under 1,000 milli-seconds.
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Timely Implementation - Rapid tooling and modular architecture implementations allow for a high level of customizability without heavy allocation of the client’s in-house IT teams. This lowered the client’s deployment time, resources and costs. The completely integrated CMS-9115-F solution was implemented in under 3 months.
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The Drummond Group Certification - This voluntary certification is a rigorous program that tests a solution’s real-world interoperability and compliance adherence. The certification proves that inherent sophisticated interoperability is built into the backend of Smile solutions. The client appreciated that Smile was the first company to achieve the Drummond Group Certification.
Continued Benefits of Implementing Smile’s HDP
Since Smile’s HDP is more than a siloed regulatory and compliance solution, the client was able to leverage it to streamline their business operations and save on costs. Built upon Smile’s FHIR-native HDP, the client developed a single API to manage security and risk across all internal applications, third-party vendors and partners, with less ongoing maintenance. This implementation freed up in-house technical and operational teams to focus on addressing their business objectives.
Since the initial implementation in 2021, Smile has continued to innovate beyond the client’s original needs. The client now leverages the HDP’s expanding capabilities, including unlimited scalability with the new MegaScale feature, and enhanced performance. This ensures secure, connected and limitless growth across their systems, beyond their goal of being able to process 64TB of data by 2025.
When the CMS-0057-F (Interoperability and Prior Authorization Final) Rule was announced in January 2024, the client was positioned to upgrade certain modules that were part of Smile’s original implementation of CMS-9115-F. The upgrades required minimal interruptions to their business workflows. As a result, the client’s data and IT architecture has all the necessary foundations and integrated workflows already configured for the CMS-0057-F Rule.
Strategic Value
There is value in going beyond the check-the-box mentality when it comes to complying with CMS regulations. Payers and Pay-viders who want to realize value-based-care outcomes utilizing Smile’s technology solutions can leverage:
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Automated ePriorAuth Claim Processing and Cycle Time - Smile’s ePA solution is compliant with CMS-0057-F and can increase the speed, appropriateness and effectiveness of care. Beyond the regulations, the solution delivers real-time data exchange, provision of transparency and coverage requirements, and automated PA responses.
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Truly Interoperable Data Fabric - Smile’s solutions create a single unified FHIR record which promotes a 360 degree view of patient/member records across the network. Synchronizing data across all systems (EHRs, labs, pharmacies, insurance etc) eliminates information silos, reduces administrative burden and improves risk management. An evolving truly interoperable data fabric leads to better patient/member care.
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Automated Clinical Reasoning - Smile’s Clinical Reasoning engine—powered by FHIR and HL7’s Clinical Quality Language (CQL) —delivers automated adjudications of prior authorization requests, proactive care gaps analysis, and real-time digital quality measures, like HEDIS and MIPS measures.