The power of connection: Redefining healthcare collaboration through payer-provider interoperability

Having a 360-degree view of patients, including clinical data, claims data and patient-generated information, is essential for delivering coordinated, safe, efficient and personalized care. This comprehensive visibility minimizes duplication of tests, prevents avoidable readmissions and ensures that every care decision is based on real-time, accurate data. Historically, payers and providers did not always exchange critical data effectively; however, value-based care (VBC) has encouraged greater data sharing to improve outcomes and reduce costs.

“Interoperability is a key enabler and accelerator of value-based care. It’s about aligning incentives around health outcomes — keeping people healthier, preventing avoidable costs and giving physicians the space to deliver better care,” said Alex Ding, deputy chief medical officer at Humana. “None of that is possible without good data flowing in a bidirectional way between the payer and provider in a way that’s as timely as possible.”

Philip Oravetz, chief population health officer for Ochsner Health in New Orleans, agreed. “We couldn’t do this on our own, and neither could payers,” he said. “Collectively, it’s about providing better care for patients.”

Ochsner Health, which includes 46 hospitals and more than 370 health and urgent care centers across the Gulf Coast, currently leverages several of Humana’s interoperability solutions to streamline workflows, optimize patient care and reduce administrative burden. It leverages similar solutions with two of its other largest payers as well.

“Our payers are at different stages of development, but ultimately, we’ll have the same functionality with all of them,” Oravetz said.

For example, Humana’s real-time pharmacy benefits solution guides Ochsner’s providers toward lower-cost medications and lower-cost pharmacies to consider. “What makes this possible is that pharmacy claims are processed in real time,” Oravetz said. “This is a goal everyone should be working toward.”

Ochsner also uses Humana’s digital ID and coverage finder solution to download more than 100,000 electronic health ID cards — a strategy Oravetz says has significantly reduced time spent retyping information and errors that can subsequently occur. In addition, point-of-care alerts reveal care gaps or unreported conditions, and the health system is currently in the process of automating prior authorizations. Currently, Ochsner submits about 20% of its requests to Humana electronically and receives real-time answers. Collectively, these innovations serve to reduce administrative burden and create more streamlined workflows across the organization.

“Payer coverage criteria is one of the best-kept secrets in our industry,” Oravetz said. “Where we’re heading is to be able to access the payer’s authorization criteria so we can use AI to read our notes and make sure we meet that criteria. We expect most services will be authorized in real time.”

Bringing data to the table

Payers and providers each have data that is beneficial to the other, which is why interoperability between these stakeholders is so important, according to Brandi Burton, enterprise transformation lead with the Humana interoperability team.

“The biggest gap for payers is when the narrative data is available in an unstructured format, such as free text notes and scanned documents,” Burton said. “All that information plays an important role in our risk adjustment, operational efficiency and supporting outcomes measurements for value-based models.”

Ding cited social determinants of health information as being particularly helpful. With the right interoperability solution, payers can abstract this data directly from a physician’s narrative without placing additional burden on providers.

Similarly, providers want to know what happens to patients outside of their own four walls, Oravetz said. When interoperability exists, health plans can provide clinical summaries to a patient’s provider from external providers, highlight procedures patients have undergone elsewhere and even offer information regarding the need to close existing gaps in care to improve quality scores.

“Patients assume all of this is already happening,” Ding said. “They expect providers to have this information at their fingertips. When this expectation is not met, they feel like the system is really fragmented, and they become frustrated.”

Overcoming barriers to progress

One of the biggest barriers to information exchange between payers and providers? Trust, Ding said.

“There must be a trusted relationship between the payer and provider that allows for the exchange of information in a more seamless way,” he said. “If the trust isn’t there, providers will be skeptical of what payers will do with that data, and they may not want to share it.”

Burton said Humana tries to address this challenge through transparency and provider feedback loops.

“This collaboration, along with cultivation of strong relationships, promotes trust,” she said.

Some providers lack the infrastructure necessary for sophisticated interoperability products. Burton said payers can address this by providing technical guidance, distributing grants to boost infrastructure or offering simpler products for integration.

Providers also have expressed concerns about privacy and security related to data sharing.

“Adopting HL7 FHIR¹ standards for data exchange, conducting regular risk assessment and ensuring [electronic health record (EHR)] vendors are doing their due diligence are essential practices,” Burton said.

Even when there is interoperability between payers and providers, they may still face challenges in actually using the data, Burton said. Patients often see multiple doctors, each using different EHRs, and payers may not receive complete information from all of them. This fragmentation leads to inefficiencies and potential delays in care. As a result, payers often receive data in multiple formats for a single member, making it necessary to normalize the information before it can be shared effectively.

Similarly, providers need robust referral networks and internal resources to act on the data they receive from payers. Payers can play a supportive role in this process.

“If we have access to social determinants of health data, hospital admissions and discharges, diagnoses and medications in real time, our care managers are able to intervene proactively, helping prevent hospitalizations,” Burton explained. “Unfortunately, the lag inherent in claims data puts payers at a disadvantage in terms of keeping members healthy.”

Less of a barrier and more of a precaution is the need for human oversight.

“We still need to manage and monitor the interoperability,” Oravetz said. “It doesn’t go on autopilot. We need to make sure there are no unintended consequences.”

Fortunately, these barriers are not deal breakers, Oravetz said. Interoperability becomes easier with each integration.

“What’s interesting is that what took us months to learn with the first payer took us weeks to learn with the second payer and days to learn with the third payer,” he said. “That’s a very steep learning curve that we and other providers across the country have experienced.”

Oravetz said the following three elements are critical to success:

1. Dedicated project management
2. Key stakeholder input, including quality, population health, IT, finance and health information management
3. Open lines of communication between payers and providers

Looking ahead: Rethinking payer-provider relations

Since implementing interoperability solutions, Ochsner Health has seen many benefits, including:

• Increased patient enrollment in care programs
• More accurate risk adjustment and quality scores
• Time savings related to record requests

Ding notes that moving to VBC payment models highlights how crucial interoperability is and marks a major shift in how payers and providers interact.

“Value-based care really does transform the payer-provider relationship from one that’s adversarial and transactional to one that’s aligned and collaborative with shared accountability for health and health outcomes,” he said. “When there are aligned incentives, there is the desire to row the boat in the same direction as opposed to rowing in opposing directions.”

Providers are moving past basic interoperability features in today’s certified EHRs to pursue advanced functionality that truly promotes VBC, Burton said.

“When interoperability works, it has the opportunity to be transformative,” she said. “It’s a win for the payer, the provider and the patient.”

Conclusion

In summary, payer interoperability solutions must go beyond technical compliance to enable real-time, bidirectional, standards-based and transparent data exchange that improves care coordination, reduces prior authorization delays and strengthens payer–provider trust. By leaning into a new era of payer-provider interoperability through technology investments and collaborative innovation and communication, healthcare organizations can strengthen health outcomes while building better relationships with consumers.

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10 key benefits of payer-provider interoperability

When payers and providers share data through sophisticated interoperable solutions, they increase the potential to strengthen the following areas:

1. Care coordination. Interoperability fosters collaboration among healthcare providers, allowing for more comprehensive care plans tailored to individual patient needs. This is vital for managing complex health issues that require multidisciplinary approaches.
2. Cost containment. Payers and providers can more effectively contain costs when they collaborate to reduce duplicate tests, minimize manual data entry and mitigate hospital admissions/readmissions. Providers can reinvest these savings into new technologies and expanded care teams. Payers can leverage cost savings from improved collaboration and operational efficiencies to enhance benefit plans for members. These savings may be used to expand coverage options, reduce out-of-pocket expenses, add new member services, or introduce innovative health and wellness programs.
3. Data integrity. With a single source of truth, providers gain reliable and actionable insights. Additionally, accurate measures of quality, outcome and cost prevent contractual disputes regarding performance, enabling transparency and promoting optimal patient management.
4. Healthcare innovation. Interoperability facilitates the development of innovative healthcare technologies and solutions, driving improvements in quality and efficiency.
5. Improved patient outcomes. Real-time data exchange helps providers make informed decisions that lead to better care coordination and management of chronic conditions.
6. Increased patient engagement. Enhanced data-sharing capabilities empower patients to take an active role in their healthcare journey. Access to their health information encourages informed decision-making and adherence to treatment plans.
7. Operational efficiencies. When systems and data are interoperable, teams focus on keeping patients healthy. They minimize time-consuming, error-prone manual tasks, including chart reviews, data abstraction and data entry — leading to reduced administrative burden on providers and staff.
8. Patient satisfaction. Patients receive timely, efficient care that includes more meaningful interactions with providers.
9. Provider empowerment: Interoperability-assisted workflows create faster and more efficient decision-making while keeping the provider informed of the status of a patient’s health.
10. Regulatory compliance. Adhering to interoperability standards and data-sharing agreements ensures compliance with healthcare regulations and promotes trust among stakeholders.

4 key industry changes propelling payer-provider interoperability forward

The following regulations and industry changes will continue to foster collaboration between payers and providers via sophisticated interoperability solutions.

1. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

Payers must:

• Digitize prior authorization through FHIR-based APIs.
• Accelerate response times and transparency.
• Empower providers and patients with easier access to data.
• Exchange clinical and authorization data across payers to ensure continuity of care.
• Comply with strict technical and public-reporting standards by 2026–2027.

Note that some of these requirements took effect on Jan. 1, 2026.

Why it’s important: Payers and providers can leverage this rule to increase patient/member satisfaction and retention.

2. CMS Interoperability Framework

CMS invites payers to voluntarily join or create a CMS Aligned Network that implements the CMS Interoperability Framework.

Why it’s important: For payers, the ability to integrate with multiple provider systems and demonstrate strong interoperability supports contract negotiations, network expansion and regulatory readiness. For providers, being a data-ready partner promotes the ability to join payer networks, secure value-based contracts and integrate digital tools.

3. HL7 Da Vinci Project

A collaborative industry effort that uses the FHIR standard to create consistent, interoperable data exchange solutions that support VBC.

Why it’s important: Creating FHIR-based implementation guides, payers, providers and vendors can exchange clinical and administrative data in a consistent, automated way. This is essential for VBC, which depends on timely and accurate data to reduce manual processes, assess performance and improve care quality. These common standards would enable interoperable, scalable VBC measures across the industry.

4. Final Information Blocking Rule

While payers aren’t the primary “actors” facing direct civil monetary penalties under the rule, they must still prepare to meet the spirit and ecosystem requirements of information-blocking prevention by being enablers of data exchange, not obstacles.

Why it’s important: Providers must share information that payers need to verify claims, conduct risk adjustment or manage value-based contracts. Similarly, payers must align their systems and policies to receive and use that data efficiently. The rule turns interoperability into a shared responsibility to promote faster care decisions, fewer administrative delays and stronger patient outcomes.

11 questions to consider when selecting an interoperability solution

Consider the following questions to ensure payer interoperability solutions ensure compliance, efficiency and return on investment.

1. Does the solution integrate directly into workflows without causing disruption or additional steps?
2. Does it integrate into existing analytics or population health tools for VBC reporting?
3. Does the solution meet ONC and HL7 FHIR standards for data exchange?
4. Does — or will — the solution fully comply with CMS requirements outlined in CMS-0057-F? Can it scale to support new regulations or additional data elements?
5. Does the solution effectively address a clearly identified business need or resolve existing operational challenges?
6. Is the solution scalable with the capacity to adapt to the ever-growing healthcare IT needs?
7. What is the implementation timeline and complexity? What resources and level of expertise are required to bring the product to full functionality?
8. How responsive is the payer-to-provider feedback or what is the response time when technical issues are experienced?
9. Is the user interface intuitive for clinical, billing and administrative staff?
10. Will the payer share roadmaps for future interoperability upgrades or expanded data sharing?
11. What are the anticipated direct and indirect costs associated with implementing interoperability solutions, including initial investment, ongoing maintenance and potential impact on existing systems and workflows?

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About Humana Inc.

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 strive to 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. To learn more about Humana’s interoperability products and how they can transform patient care, visit provider.humana.com/working-with-us/interoperability.  Learn more about what we offer at Humana.com and at CenterWell.com.

_{This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.}

Footnotes

[1] Health Level Seven International (HL7 Fast Healthcare Interoperability Resources (FHIR)