Nick Yarker

Our podcast series continues.....Navigating the dynamics between payers and providers presents unique challenges. In this episode of The MRO Exchange, Matt and Christopher delve into these complexities, exploring the vital role of patient data and the responsibilities surrounding data access. Tune in for insights: https://okt.to/BGyAD2

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It's been 8 months since CMS announced its final rule on prior authorization (PA) and interoperability. As we come closer the implementation deadlines, it's crucial to assess our readiness and understand the broader implications. The CMS rule on PA requires some key things: 1️⃣ Faster PA decisions (72 hours urgent, 7 days standard) start in 2026 2️⃣ FHIR-based Prior Authorization API implementation 3️⃣ Expanded Patient Access API and new Provider Access API from 2027 4️⃣ Affects Medicare Advantage, Medicaid, CHIP, and certain QHP issuers 🔗 The FHIR APIs Required by 2027: Enhanced Patient Access API: Now includes prior authorization data Provider Access API: Allows providers to access patient data from payers Payer-to-Payer API: Facilitates data exchange when patients switch payers Prior Authorization API: Streamlines the prior auth process 🔍 What's Missing? 1️⃣ FHIR Standard Adoption: Payers must use FHIR standard queries, but EHR changes aren't mandated. 2️⃣ EHR Integration Gap: The rule doesn't require direct EHR interrogation for PA requests, which could have eliminated most administrative friction. 3️⃣ Digital Endpoint Challenge: Payers need to discover digital endpoints for each entity, but there's no centralized database yet. 4️⃣ Medication-related PA inclusion 5️⃣ Other revenue cycle FHIR standards: While the rule addresses PA, it doesn't tackle the myriad other reasons for claim denials (e.g., coding errors, eligibility issues, medical necessity disputes). 🔍 Where are we now? - Many organizations are in the planning or early implementation stages - CMS is exploring a National Directory of Healthcare Providers and Services, potentially including payer endpoints. (https://lnkd.in/ghf28bDF) - Prior Authorization support has been built in to some of the most common implementation guides for FHIR (https://lnkd.in/gKP4Qdzn) 🤔 Critical questions at this stage: 1. How far along is your organization in preparing for these changes? 2. What unexpected challenges have you encountered in the implementation process? 3. How are you balancing these PA improvements with other revenue cycle optimization efforts? Let's share experiences and best practices. What insights can you offer to peers navigating this transition? #HealthcareIT #PriorAuthorization #Interoperability #RCM #RevenueCycle #CMS https://lnkd.in/gHB_i9Gu https://lnkd.in/gjegKF4g

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Here’s your recap of last week’s health IT news 🗞️ 👇 🤖 AI Clinician Assistant • Oracle Health announced the release of its AI-powered clinical digital assistant, which integrates “clinical automation, conversation-based note generation, and proposed clinical follow ups” directly within the EHR. • NextGen Healthcare released a version of their Ambient Assist designed for small practices, which includes Spanish support and specialty-specific workflows.    • Community Health Network has begun a multiyear Microsoft implementation including Nuance Communications Dragon Medical One and DAX Copilot. 🧑‍💻 Virtual and At-Home Care • Hackensack Meridian Health partnered with Medically Home to implement their hospital at home program. • Cleveland Clinic is integrating Masimo’s wearables in a new partnership focused on hospital-based RPM. • eVisit acquired UPMC Enterprises' inpatient teleconsult technology and an investment from UPMC’s innovation and investments arm as part of their $45M Series B funding. • PatchRx released an API-based tool allowing providers to sync data directly into their existing care platforms. 📊 Data & Analytics • Atropos Health added two new partners and a data scoring system to allow users to select the most appropriate datasets for their queries. • Xealth launched a metrics tool that allows customers to measure and track patient engagement with their digital health programs. 📋 Patient Administration • Fabric acquired MeMD from Walmart. 🔄 RCM • Inovalon joined MEDITECH’s interoperable product marketplace. • RevSpring released an update that integrates a lockbox solution for check processing within its existing payment platform. • Solventum Revenue Integrity (fka 3M Health Care) released its new AI CDI software powered by Sift Healthcare, Solventum Revenue Integrity System, which uses machine learning to predict denials before they happen. 🍎 VBC Data & Analytics • Arcadia acquired CareJourney leveraging their cost, quality, and benchmark data to enhance Arcadia’s data, analytics, and workflow tools. • Adventist Health selected The Garage In's population health management platform to support its VBC operation. 🧠 Food For Thought •  Coalition for Health AI (CHAI) released its draft standards guide for public comment. https://lnkd.in/eMUXGfvz • We really appreciated Daniel Yang, MD’s post about a recent article on the emergence of a new leadership role: the Chief Health AI Officer (CHAIO) https://lnkd.in/ejZxnJCj --- Reminder: you can sign up for the Elion Briefing to get the latest healthcare tech news delivered to your inbox each week 📬 👉 https://lnkd.in/e2UJ3ckP

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Thinking out loud today: The average Healthcare System CIO tenure is slightly below 4 years (this seems to be the average # of years across a few different publications) yet we are seeing CIO searches take between 6-8 months, sometimes longer. Can someone explain to me why? - Why are we still following this archaic "House Hunters" syndrome of executive placement where we continue to have Pappy Van Winkle expectations on a Jack Daniels budget (sorry but yes, I'm a bourbon guy). - Why do we continue to want our digital leaders to be in a confined location (aka relocate) but yet we expect them to be at the forefront of geographic agnostic solutions like the Digital Front Door, Remote Patient Monitoring, Hospital at Home and everyone's favorite, cloud-first solutions. Not to mention, Health Systems continue to expand across multiple state lines through mergers and acquisitions. - Why do we continue to spend millions in new or first-time technology but rarely ever give someone their first chance at being an executive. - Why do we continue to complain about staffing shortages or the perceived "lack of talent", but we do nothing to actually build the talent pool. Again, just thinking out loud...

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Instead of using a third-party app, consider a license for the validated MMAS scales directly into your EHR. Here’s why: ✅ Simplified Licensing – Fewer terms, less hassle. 💸 Cost-Effective – No hidden software fees. 🔒 Better Data Security – Keep patient data in-house. 💻 Customizable Workflows – use internal Large Language Learning models that you control. Tailored for your clinicians. 🕒 Independence from Vendor Support – Manage updates on your schedule. Think about the benefits of keeping validated tools close to home. Better efficiency for your team, better outcomes for your patients! www.moriskyscale.com #HealthcareInnovation #EHR #PatientCare #HealthcareTech #ClinicalWorkflows #MedicationAdherence

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Intro to my new series about #ACO strategies for cost control using aggregated data. You'll need a number of concerted strategies designed to pursue better patient care and outcomes. #dataaggregation #valuebasedcare https://lnkd.in/gPiXp8xc

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Grateful to be a part of this team and our overarching mission… Empowering patients with simplified, actionable, and predictive healthcare insights is a key to improved health outcomes. Not only does Healthyr augment and amplify the efforts of organizations delivering healthcare today- but our platform equips patients with the solutions needed to own their health, closing one of the final gaps that remain in the value-based care ecosystem, for future success. #ValueBasedCare #PersonalizedCare #Health #HealthcareInnovation

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The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) released last January builds on previous initiatives to reduce administrative burdens for both Payers and Provider ... advancing EMR interoperability within the prior authorization workflow through HL7® FHIR® transactions. Key Benefits Include ... - Improved decision-making and outcomes through real-time access to comprehensive patient records and CDSM. - Automation of requests directly from the ordering Physician platform. - Member / Patient empowerment through transparency and access to their health data. I’m excited about these advancements, witnessing improved efficiencies within HealthHelp's own operations. Let me know if you would like to continue the conversation. #HealthcareInnovation #Interoperability #PriorAuthorization #PatientCare #HealthTech

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𝐓𝐡𝐢𝐬 𝐢𝐬 𝐬𝐨 𝐢𝐦𝐩𝐨𝐫𝐭𝐚𝐧𝐭 𝐭𝐨 𝐭𝐡𝐞 𝐋𝐓𝐏𝐀𝐂 𝐜𝐨𝐦𝐦𝐮𝐧𝐢𝐭𝐲. But the ruling could also have broader implications for data privacy and particularly around the use case of analytics companies having broad access to patient health information. I can imagine that this might also have implications for LLM training data, as AI continues to march throughout the healthcare ecosystem. Real Time Medical Systems alleges that PointClickCare (PCC) is blocking its access to EHR data by using security ciphers. Real Time claims this is an anti-competitive move following PCC's expansion into post-acute analytics. A judge appears likely to block PCC's actions, emphasizing the need for data access to improve patient care as mandated by the 21st Century Cures Act. This may enhance interoperability, but there is a lot to consider. Thank you Brendan Keeler for bringing this important topic to light.

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Let us know how we might work with you on your unique needs

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I’m thrilled to share an insightful post featuring Tony McDonough, SVP and William Fleming, PharmD, Healthyr Advisor, as they delve into Healthyr's commitment to solving one of healthcare's biggest challenges—fragmentation. At Healthyr, we’re creating a seamless healthcare experience through interoperability and AI-driven tools that ensure data flows smoothly across more than 90 EMR systems. This integration of EMRs, wearables, and patient-reported information enables real-time insights that make the healthcare journey easier for both patients and providers. With tools like AskHealthyrAI 🤖, patients can access personalized health insights, medication reminders 💊, and lifestyle advice 🥗 tailored to their individual needs. Meanwhile, providers benefit from a reduction in administrative burden 📋, allowing them to focus on what matters most—patient care. The future of healthcare isn’t just about innovative technology; it’s about delivering compassionate, connected care. At Healthyr, we’re building that future today—one where technology empowers both patients and providers to achieve better health outcomes and more meaningful interactions. 🚀 Tony M.Chris CaudillFabio BaglioniWilliam Fleming, PharmDPaul MuretMichael P. MillerJohn HalseyLauren Jones, MDJay FinsterRobert Pearl, M.D.Shannon Hendrix, MS, RD, LD, FACHENery Gomez #HealthcareInnovation #Interoperability #AI #DigitalHealth #PatientExperience #HealthTech #PersonalizedCare #ProviderSupport #Healthyr

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Let's discuss the escalating payer-provider tug-of-war now mediated by AI in healthcare interactions. Our own Amit Phull dove into the impact of AI in revenue cycle management, claims processes, and patient experiences within the healthcare industry. Is it time to unleash your army of algorithms? Let's navigate through the AI arms race and its implications together! 💡 🏥 Providers are turning to AI to predict and reply to denials, whereas payers are countering with AI to detect upcoding, raising vital questions about the evolving landscape of healthcare interactions and the patient journey. It's time to empower patients to navigate the maze of chatbots and automated systems for clarity regarding their coverage without needing a PhD in machine learning. Let's ensure that patient-centricity remains at the core of the AI transformation journey! While AI promises to reduce costly claims denials and improve efficiency, we must address concerns about potential cost escalations and the necessity for new regulatory frameworks, such as AI-specific CPT codes. The future of AI in healthcare depends on effective rulemaking—let's shape it together! 🤝 At the end of the day, AI is a tool shaped by human rules. Let's harness the power of AI while ensuring that it enriches, not overwhelms, the healthcare journey. 🦾 Let's work together to create a future where AI drives positive patient outcomes without transforming healthcare into a scene from The Terminator! ⚕️ #HealthcareAI #DigitalHealth #PatientCentricity #AIInHealthcare #HealthcareInnovation #HealthTech #PatientExperience #AIRegulations #DigitalTransformation #HealthcareLeaders #AIImplements #HealthcareJourney 🏥 https://lnkd.in/e49XMAnE

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The decision to outsource a function requires thought and due diligence. Listen to how we supported Core Clinical Partners in that journey and provided value beyond the day to day.

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Driving digital engagement and optimizing data management is crucial for healthcare organizations. Industry experts from Maimonides Medical Center, Sanford Health, and Centene Center for Health Transformation discuss breaking down silos and leveraging technology solutions to enhance data management. Watch the replay moderated by Cheryl Griffin from Verato for more insights.

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Deep dive on Interoperability as it relates to Providers / Payers from us at INFUSE Health. Would appreciate your perspective as well and how this topic continues to resonate with your key audience segments from a GTM standpoint.

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Simplifying Prior Authorization: Why It’s Time for a Change Healthcare providers and patients alike face a major roadblock with prior authorizations. Lengthy approval times, miscommunications, and back-and-forth calls between payers and providers often delay essential treatments. The result? Frustrated patients, overworked staff, and rising administrative costs. At #AppZHealth, we’re working to transform this process with smarter automation and real-time updates. Imagine a world where prior authorizations are streamlined, approvals are faster, and providers spend more time caring for patients instead of chasing paperwork. Let’s redefine what healthcare efficiency looks like. What’s been your biggest struggle with prior authorizations? Let’s discuss solutions! #HealthcareMeetsFinTech #PriorAuthorization #HealthcareSimplified #AppZHealth #MedTech

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On the list of healthcare workflows ripe for gen AI disruption, prior authorization ranks near the top. While the logic for prior auths is justifiable (i.e., ensuring appropriate utilization and that care aligns with evidence-based practices), the logistical burden is often crushing. Providers have to create orders, run eligibility checks, submit requests, fill out forms, send medical records, and communicate through web portals, faxes, and phone calls—all simply to get care approved. There’s hope on the horizon though. AI-enabled solutions are emerging to reduce this administrative burden. We’re seeing many new entrants in the AI-Enabled Prior Authorization for Providers space covering a range of use-cases, like: 💊 Medications: The focus here is split between oncology drugs, specialty infusion drugs, and popular drugs like GLP-1s. (Examples: Develop Health, SamaCare, tandem, and Latent) 🏥 Procedures, acute care, and post-acute care: This is an area of focus for health systems, but there are fewer AI-enabled vendors in this space at the moment. (Examples: AKASA, Myndshft, and Ethermed) 🩼 Specialty-specific: Some vendors have chosen to focus on other, more niche areas where PAs are common. (Examples: Silna Health for therapy, or Synthpop - Healthcare AI for DME) Looking to the future, there’s an opportunity for clinical decision support in the EHR, clinical summarization, and advancements in interoperability to better support structuring of clinical data and form-filling, further streamlining the authorization process. We’re taking a deeper dive into prior authorization soon (including vendors focused on the payer side)—what questions would you like answered?

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Exciting! ChristianaCare is transitioning to Epic, and as health systems embrace advanced tools, whether executives choose to move from Cerner Corporation to Epic or vice versa, I urge them to prioritize data and AI usability. A Deloitte survey emphasizes that healthcare leaders must focus on data, governance, patients (customers), and care staff to successfully implement generative AI. Data considerations, including availability, reliability, and quality, are critical, with quality being the most challenging to validate. My suggestion is to involve AI partners in these conversations to ensure EHR systems meet market and patient demands. Don't fall behind; your competitors are already doing it, and your patients expect it! Let's make it happen!" Cohere https://lnkd.in/eAGcmGV3 #healthinnovations #AIinHealthcare #EHRTransition #DataGovernance #GenerativeAI #HealthcareInnovation #PatientExperience #CompetitiveAdvantage #AICollaboration #EHRUsability #DataQuality

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