In this episode, Ashley Basile, Availity Chief Product Officer of Clinical Solutions, discusses one of the most critical advancements shaping the future of healthcare: payer-to-payer data exchange.

The healthcare industry stands at a pivotal moment as it works to address one of its most persistent challenges—seamless data sharing. On January 1, 2027, the Centers for Medicare & Medicaid Services (CMS) will enforce the Payer-to-Payer Data Exchange Final Rule, requiring health plans to implement APIs for sharing critical clinical, claims, and authorization data when members transition between plans.

This rule has the potential to revolutionize how data flows across the healthcare ecosystem, ensuring that patient information follows them, regardless of where they receive care. However, as Ashley explains, it’s not without its hurdles.

In this episode, Ashley delves into the findings from Availity’s groundbreaking Payer-to-Payer Data Exchange Cohort Program. This initiative brings together leading health plans to identify and overcome the hidden challenges of payer-to-payer data exchange.

We discuss strategic approaches to innovation and mental models for devising clear goals and outcomes among diverse stakeholders.

Thoughts? Guest suggestions? Email us at matt.schlossberg@availity.com

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich & Derrick Nevado.

Additional Reading

• Availity Payer-to-Payer Resource Hub: LINK
• CMS Payer-to-Payer Data Exchange Final Rule | LINK

Our guests are Amanda Clifton, Vice President, Technology Solutions, Automation and Core Workflow and Jeffrey Bostelman, Staff VP Interoperability, Clinical Strategy & Architecture, at Centene Corporation.

In this episode, Amanda and Jeff explore the opportunities and challenges of payer-to-payer data exchange and price transparency regulations.

On January 17, of this year, the Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Final Rule, a significant step towards improving member data exchange and delivering holistic care experiences.

With the January 1, 2027, mandatory enforcement date approaching, failure to take proactive steps could result in substantial penalties and connectivity delays. This underscores the urgent need for health plans to act swiftly and decisively to address the challenges and hurdles in establishing secure connections with other health plans.

Price transparency is a series of national policies designed to create a patient-driven healthcare system by making health plans and hospitals in the U.S. more transparent, so patients can better understand what they will pay for goods and services.

Consumerism is built on the tenet that patients have full access to cost and pricing information to make decisions about their health, and these new laws are likely just the start of a series of regulatory initiatives designed to mandate pricing transparency.

Thoughts? Guest suggestions? Email us at matt.schlossberg@availity.com

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich & Derrick Nevado.

Learn More

• Availity’s Interoperability Solutions Payer-to-Payer Hub and Prior Authorization Requirements, Documentation, and Decision (PARDD). This webinardelivers an overview of Availity’s approach to two mandates in the CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P), also referred to as Interop 3.

Pankaj Jain is Vice President at Highmark Health. Pankaj leads the enterprise Product Realization Office with the mandate for value effectuation of all medical insurance and technology products. Pankaj is at the forefront of promoting digital health and value-based care through various global research endeavors, conferences, virtual events, and by leading enterprise transformations at Highmark that improve healthcare delivery for providers, payers, and consumers. Prior to foraying into healthcare, he led global businesses for Siemens, Rockwell, and GE.

In this episode, Pankaj talks about innovation and change management. In the ever-evolving landscape of healthcare IT, innovation and change management play pivotal roles in shaping the future of patient care. The opportunities that arise from embracing cutting-edge technologies are immense, promising enhanced efficiency, streamlined processes, and ultimately, improved health outcomes. From artificial intelligence optimizing clinical and administrative processes to the seamless integration of electronic health records, the potential for positive change is boundless.

However, with great potential comes great responsibility. Navigating the delicate balance of innovation in health IT presents a unique set of challenges. In a realm where patient lives hang in the balance, precision and reliability are paramount. Ensuring the seamless adoption of new technologies while maintaining the highest standards of safety and privacy demands a strategic approach.

We discuss strategic approaches to innovation and mental models for devising clear goals and outcomes among diverse stakeholders.

Thoughts? Guest suggestions? Email us at matt.schlossberg@availity.com

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich, Derrick Nevado, and Alexis Valladares.