Beyond the CMS Mandates: A Payer Strategy
A leading US insurance payer is using their rapid achievement of compliance with CMS-9115-F to fast track and accelerate beyond CMS-0057-F mandates. With their digital transformation built upon Smile’s FHIR-native Health Data Platform, they are strategically positioned for operational efficiency, increased ROI, and value-based care initiatives.
Read or watch our video, outlining this use case, where we not only helped an HIE modernize their IT infrastructure, but also set their foundation for continuous innovation.
Summary
The client: The client is one of the US’s leading health insurance payers and benefits providers. They service over 5 million members across 13 states with over 25 lines of business.
The challenge: With no in-house access to the requisite technical resources, the client had to be fully compliant with the CMS-9115-F Patient Access Final Rule by July 1st 2021 in order to avoid fines. By March 2021, they had not yet chosen a compliance vendor, and were managing competing large-scale internal projects at the time—including attempting to consolidate their disparate data sources.
The objective: The CMS-9115-F Rule was highly disruptive for the client, as it was for many payers, who had to quickly maneuver and address the compliance requirements. Their objectives were:
A.) To be fully compliant before the enforcement date of July 1st, 2021,
B.) Minimal disruption to their ongoing internal projects, priorities and timelines
C.) Accelerating their cloud strategy
D.) Maintaining complete ownership and access to their data
E.) Rapidly learning and adopting FHIR®—healthcare’s leading global interoperability open standard for data exchange
F.) Consolidating and transforming their fragmented and unstandardized data to FHIR
The Solution
The client engaged with Smile Digital Health in April 2021. With a combination of our expertise with compliance implementation for Payers, and our out-of-the-box suite of solutions, their requirements were exceeded. Smile’s Health Data Platform is now the client’s comprehensive FHIR-native data repository. Upon this platform, a precursor of the CMS Suite was built, giving the client full compliance with the CMS-9115-F Rule within 3 months of signing the contract. They were compliant well before the enforcement date, and all their objectives were satisfied. In addition, the client also achieved:
- Increased member engagement with clients accessing their claims and clinical data through the new FHIR APIs
- Preemptive completion of the Payer-to-Payer module—not required as part of the finalized CMS-9115-F Rule—but a requirement of the upcoming CMS-0057-F Rule.
- Early preparedness for the CMS-0057-F Rule, having completed the work of integrating all their disparate data sources into FHIR, with strategic architectures completed to ensure future-ready compliance
- Burden reduction within their Quality Teams with higher accessibility of FHIR data from all formats (paper and digital)
- The ability to run continuous HEDIS measures in real-time throughout the year, with their FHIR data models
- The mechanisms to scale their HEDIS measures to several of their 25 lines-of-business, thereby reducing the overall cost of care, and enhancing their reimbursement potentials
Smile Digital Health continues to provide on-premise support to the client on their cloud, including all configurations and ongoing maintenance.
Advantages of Smile’s Platform and Compliance Solutions
Meeting mandates, like CMS-9115-F and the upcoming CMS-0057-F are regulatory requirements that all payers have to meet to avoid penalties. However, strategically implementing compliance solutions that support value-based care, unlocks significant long-term ROI. For our client, and other innovative payers, compliance was only the first step; they quickly recognized the broader benefits that transformed their operational efficiency and business capabilities.
- Designed for Re-usability: Smile’s Health Data Platform is extendable, allowing initial implementations to support future ones with minimal additional effort. This capability enabled our client to achieve CMS-9115-F compliance while also laying the groundwork for CMS-0057-F and use cases like HEDIS quality measures. Each additional use-case becomes easier and more cost-effective to implement, building cumulative value across the organization.
- Streamlined Operations: The Health Data Platform leverages FHIR-based APIs to offer complete compliance, without compromising risk, security and performance. Our customizable platform can enable access through consent controls, thereby reducing risk and enhancing security, even when third-party apps are involved. These streamlined operations simplify data sharing and contribute to a smoother, more efficient ecosystem.
- Future-proofed Toolkit of Capabilities: The Health Data Platform includes a range of tools, such as Master Data Management, FHIR Gateway, SMART on FHIR integrations, and a FHIR-CQL engine, that equip the client for evolving needs. These capabilities facilitate the validation of digital quality measures, continuous quality analytics, automate prior authorization processes, enable real-time analysis of care gaps, and enhance risk adjustment accuracy.
Conclusion
With a secure and scalable FHIR-based platform already in place, our client is primed to leverage their investment across network-wide business and compliance needs. Each successive use-case builds on their initial implementation, adding substantial value without requiring redundant effort or costs. Smile’s CMS Suite further streamlines the API framework needed for the upcoming mandates, keeping the client agile and fully prepared for future regulatory changes.
The US healthcare system is moving towards a value-based care system that directly ties payer reimbursements to the delivery of measurable high-quality clinical data. Our client’s early investment in a comprehensive, quality-focused data platform positions them to capture significant cost savings, optimize care delivery, and maximize reimbursements. By moving beyond compliance and embracing digital transformation, they are not only fulfilling regulatory requirements but also establishing a foundation for long-term success and a competitive edge in a rapidly evolving industry.