How APIs Help Connect Healthcare Payers and Providers

Patient data is like oil for healthcare payers, fueling every aspect of their operations. But research shows that a lack of data sharing between payers and providers impedes risk-sharing initiatives – and ultimately harms all parties.  

This article explores how healthcare APIs can help them solve this problem – improving patient care, risk management, and health plan performance in the process. But before we explore how that works, let’s establish exactly what we mean by “API”. 

Healthcare APIs: An Executive Overview 

What is an API? 

An Application Programming Interface (API) is a “bridge” between two computers, allowing disparate software applications to interact. They allow data and functionality to be shared between systems without the need to understand complex internal workings – which is vital for healthcare interoperability. 

Why Are APIs Important for Healthcare? 

The ability to share, receive, and store information between healthcare systems and software applications is vital to deliver robust, timely patient care. Imagine if you had to wait four hours every time you needed to access a patient’s medical charts or view scans; it would bring the entire operation to its knees. 

This ability to move data between systems is known as “healthcare interoperability” and it is one of the most persistent challenges faced by modern providers. There are multiple factors which make interoperability difficult, but the primary ones are: 

• Security Risks: Healthcare data is highly sensitive and heavily protected through HIPAA, meaning its transmission must meet high security and privacy standards. Failure to adhere can lead to seven-figure fines and even jail time. 
• System Complexity: Healthcare IT systems are enormous, with hundreds of pieces of machinery and software connected – many of which are either outdated or run by third-party vendors. This creates a wider “risk surface” and makes healthcare IT particularly vulnerable to cyberattacks. 

The net result? Healthcare providers must simultaneously deliver fast and fluid data flows while maintaining robust security across a complex and often-vulnerable IT system.  

APIs solve this problem by enabling interoperability that is limited to specific accesses. They define the methods and data formats that applications can use to request and exchange information, streamlining integration and enabling the creation of complex, connected systems. Today nearly three-quarters of providers use APIs, but their use is also expanding to unlock more effective collaboration between providers and healthcare payers.  

Why Payers and Physicians Must Share Data 

Sharing data between patients and payers is essential for two core reasons:  

1. Patient Care

Providers often need data to assess whether a patient’s care will be covered – but they need it fast. Imagine a scenario where a patient needs urgent surgery, but delays occur because the provider cannot quickly verify insurance coverage or treatment pre-authorization. These delays can compromise care quality, increase costs, and frustrate patients.

2. Plan Management

Payers need access to claims files and HCC codes to undertake a range of important tasks: 

• Predict Costs and Allocate Resources: By identifying high-risk patients with chronic or complex conditions, payers can allocate resources for care management programs, reducing the likelihood of costly hospitalizations or emergency visits. 
• Design Tailored Plans: Payers can customize health plans to include benefits like disease management programs, preventive care, or telemedicine services targeted to specific patient groups. 
• Improve Risk Adjustment Accuracy: Accurate HCC coding ensures payers receive appropriate compensation under Medicare Advantage and other risk-adjusted reimbursement models, supporting the financial sustainability of their plans. 
• Enhance Population Health Management: Analyzing HCC data helps payers identify trends and implement proactive strategies, such as addressing gaps in care or promoting preventive screenings for at-risk populations. 
• Collaborate with Providers: Payers can share insights with providers, fostering collaboration to deliver coordinated, patient-centered care and meet shared quality goals. 

All of which seamless data sharing a major priority – so why is this still so rare? 

Why HCC Coding Insights Are Difficult to Share 

The relative lack of interoperability between healthcare providers and payers can be explained in three ways: 

• Fragmented Patient Data: Many providers simply lack a single centralized view of patient health to share with payers. Information is stored across multiple IT systems and formats – with much of it “unstructured”. 
• Integration Costs: Building an EHR integration that will share insights with payers is complicated and expensive. Custom builds may simply not fit the provider’s budget or create extra complexity their IT team struggles to justify. 
• Compliance Concerns: Regulatory scrutiny is high within healthcare, making new integrations a high-risk and potentially disastrous investment – especially when you are building them yourself. 

However, each of these challenges can be solved with the right technology – and Inferscience has embedded it all within a single solution. 

Enhance Care Insights and Risk Adjustment with HCC Assistant 

HCC Assistant is an innovative tool that uses natural-language processing (NLP) to streamline risk adjustment workflows and enable more effective collaboration between healthcare providers and payers: 

• Improve Documentation: Centralized structured and unstructured patient data to create a complete view of your patients’ medical histories and care requirements. 
• Simplify Risk Adjustment: Generate automated HCC coding recommendations with 98% accuracy. 
• Integrate Analysis: Allow payers to use our exclusive API to access HCC coding analysis with ease – and make more informed decisions. 

Want to explore how it helps the average organization increase risk adjustment factor (RAF) scores by 35%? 

Book a Demo