Seamless Data Exchange Improves Patient Access to Care, Reduces Administrative Burden Across the Healthcare Ecosystem

athenahealth, a leading provider of network-enabled software and services for medical groups and health systems nationwide along with collaborators Availity, Harmony Park Family Medicine, and Humana (NYSE: HUM), received a 2024 Points of Light Award from KLAS. The group’s case study, “Using FHIR Standards to Streamline Prior Authorization Management & Improve Patient Care,” recognized the organizations’ work together to modernize the prior authorization process and expedite approval of prior authorization requests.

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Prior authorization is the process used to obtain insurance approval for medications and certain medical procedures before they can be performed. It is designed to ensure that patients receive timely, clinically appropriate, evidence-based care. This collaboration aims to deliver an end-to-end process that streamlines, automates, and reduces administrative burdens to the benefit of all parties involved.

“Our mission is to ensure that our members can get the high-quality, affordable care they need while delivering the better health outcomes they deserve,” said Angie Shaw, Humana’s Vice President of Clinical Operations Shared Services. “By partnering with athenahealth, Availity, and Harmony Park, as well as others in the industry, we are working to streamline the prior authorization process in ways that improve patient access to care and deliver better health outcomes.”

Humana, Availity, and athenahealth worked together to develop an automated electronic prior authorization (EPA) process leveraging the Da Vinci Burden Reduction Implementation Guides – a set of standards designed to make the process of prior authorization in healthcare more efficient and streamlined – to expedite approval of these requests and deliver a better, more seamless end-to-end experience for patients, providers, and payers.

One of the key achievements of the project was Availity creating a seamless data exchange to connect the Humana and athenahealth platforms, allowing data to be effortlessly exchanged. “Unlike many healthcare transactions, prior authorization is not always a simple query and response but can be a complex conversation, and that’s why we’re working to improve this process for beneficiaries, providers and payers," said Russ Thomas, CEO of Availity. “We are proud to be recognized for our collaboration with athenahealth, Harmony Park, and Humana.”

The EPA process has saved Harmony Park 24 hours per week in manual work that can now be redirected to patient-centric activities. “With this new automated prior authorization process enabled within the athenahealth EHR, our providers now have all necessary information and requests directly within their workflow,” said Yvonne Dooley, Chief Operating Officer, Harmony Park Family Medicine, a provider in Hot Springs, Arkansas that is successfully using the tool. “This, combined with the speed and transparency we now have throughout the entire process, has greatly reduced administrative burden for our staff, and patients are able to receive care more quickly in anticipation of improved health outcomes.”

Key outcomes of the collaboration, detailed in the case study, include quicker patient access to care, improved provider efficiency, and decreased administrative burden as compared to when the workflow is entirely manual. Stakeholders determined that during the evaluation period, nearly 54% of all requests per month required no authorization, and 70% of prior authorization requests processed through the implementation were instantly approved by Humana, due to the integration that enables robust data gathering and sharing. These instant approvals have contributed to a dramatic reduction in turnaround time from multiple days to about one day, which far exceeds industry averages that range from days to weeks and the seven-day target established by the CMS Interoperability and Prior Authorization Final Rule.

“At athenahealth, we take on and automate time-consuming, manual tasks so that practice staff can focus on supporting patients,” said Paul Brient, Chief Product Officer at athenahealth. “We are thrilled to work with our partners and customers to modernize the process associated with prior authorization. This type of industry collaboration can simplify the practice of care and drive meaningful improvements for providers, patients, and payers.”

The KLAS Points of Light annual awards celebrate success stories achieved by payers, healthcare organizations, and healthcare IT companies who have partnered to reduce costs and inefficiencies and improve the patient experience. The awards were presented at the KLAS K2 Collaborative Summit, May 14-15 in Salt Lake City.

To learn more about the challenges, outcomes, and key lessons from this collaboration, please visit: https://www.athenahealth.com/KLAS-POL-2024.

About athenahealth

athenahealth strives to cure complexity and simplify the practice of healthcare. Our innovative technology includes electronic health records, revenue cycle management, and patient engagement solutions that help healthcare providers, administrators, and practices eliminate friction for patients while getting paid efficiently. athenahealth partners with practices with purpose-built software backed by expertise to produce the insights needed to drive better clinical and financial outcomes. We’re inspired by our vision to create a thriving ecosystem that delivers accessible, high-quality, and sustainable healthcare for all. Learn more at athenahealth.com.

About Humana

Humana Inc. is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services, and our CenterWell health care services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

About Availity

Availity is the trusted partner for organizations seeking to realize the greatest value from clinical, administrative, and financial data. Positioned at the nexus of provider, health plan, and consumer health information, Availity develops scalable, innovative solutions for healthcare data acquisition, standardization, transparency, automation, and exchange among health plans, providers, and technology partners. As one of the nation's largest health information networks, Availity facilitates billions of clinical, administrative, and financial transactions annually. Our suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment.

For more information, including an online demonstration, please visit www.availity.com or call 1.800.AVAILITY (282.4548). Follow us on LinkedIn and X.

About Harmony Park Family Medicine

Harmony Park Family Medicine, located in Hot Springs, AR, is committed to offering professional, compassionate, and coordinated patient care. Harmony Park provides patient-centric care, wellness services, and a specialized chronic care management program, as well as convenient online portal access to appointment scheduling, health records and results, and online bill payment. Learn more at harmonyparkfamilymedicine.com.

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