Ron Urwongse

Using Payer APIs to Improve Mental Health Networks

In our last article, we explored mental health ‘ghost’ networks as discussed in the May 3rd Senate Finance Committee hearing. We summarized the multiple causes of the problem and potential solutions. In this piece, we will explore how existing interoperability requirements for payer directories can be leveraged to support new solutions. The specific requirements we’ll …

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How many payer contracts do providers have?

Knowing the number of payers that providers contract with is important for a few reasons. Reason 1: It is a proxy for administrative burden. The number of contracts can be a useful proxy for the administrative burden that multiplies as a provider contracts with more payers. This includes such tasks such as enrollment, credentialing, contracting, …

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What a good developer experience looks like: VA Lighthouse

In our previous post, we reviewed the status of payer provider directory APIs and learned that some payers take a compliance-only mindset towards interoperability. Poor developer experiences are characterized by limited or non-existent documentation, broken APIs, and no communication channel to report issues. What does good look like? If we look among the payers, UnitedHealthcare, …

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Provider Directory APIs: Beyond a Compliance-Only Mindset

State of Payer Compliance on Provider Directory APIs It has been 18 months since the July 2021 effective date of the CMS Final Rule on Patient Access and Interoperability. In January 2022, we had identified Provider Directory APIs from 128 payers. Since then, we observed 78 additional payers publishing Provider Directory APIs. The addition of …

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Responses to the CMS RFI on National Healthcare Directory

In response to CMS’s RFI on a National Healthcare Directory (responses were due Thurs 12/6/2022), over 600 responses were submitted (around 50% of these were part of two major cut/paste campaigns, making the responses difficult to navigate on Regulations.gov). We reviewed and summarized the responses by industry segment. We also excerpted statements and linked to …

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A Review of the CMS RFI on National Healthcare Directory

Executive Summary: CMS describes a National Healthcare Directory that will streamline provider data collection and promote interoperability. Years of industry engagement have produced layers of additional use cases. CMS should consider focusing on foundational data and not prematurely adding scope until it has established a complete, accurate provider demographic data set. CMS should also consider …

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Health equity and languages spoken

The Need for Linguistically-Appropriate Services On April 20, 2022, CMS released an action plan that establishes health equity as a ‘first pillar’ of its strategic vision under the Biden-Harris Administration. Included in its priorities are two actions that consider languages spoken: Promote culturally and linguistically appropriate services to ensure understandable and respectful care and services …

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The Importance of Health Plan Information and Identity

Defacto Health has been reviewing health insurers’ Provider Directory APIs in terms of availability, issues, and use cases for almost a year now. This post is a continuation, and we are focusing on the importance of health plan information within the APIs. While many exchanges between patients and providers about insurance stop short at “Do …

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Using Provider Directory APIs to assess provider network size

When CMS issued its requirement for payers to publish Provider Directory APIs, it contemplated use cases such as in-network provider search and health plan shopping. Consumers shopping for health plans want to check whether their preferred providers are in-network, but they are also likely interested in the robustness of the network. Carriers may lever up …

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