Edifecs

With granular, computable consent, health plans can ensure that members' data privacy preferences are applied consistently across all channels, providing a seamless experience and reducing administrative burden. In a recent blog post, Kevin Day took a closer look at the benefits and key considerations of granular, computable consent: https://hubs.ly/Q04hYvKT0

Building a strong data foundation is both the greatest challenge and the greatest opportunity for payers and providers pursuing success in value-based payment. Edifecs' latest blog outlines how organizations can address system fragmentation by using data governance frameworks and normalization layers, embedding SDOH screening into routine clinical workflows to close care gaps, and integrating AI responsibly to identify high-risk patients earlier and enable targeted interventions. Read the full blog: https://bit.ly/4f9EDcW

An often-overlooked benefit of investing in FHIR is its ability to support more effective data privacy controls through granular, computable consent management. Kevin Day discusses the enterprise benefits in this blog post: https://hubs.ly/Q04hYvKT0

Transitioning to value-based payment contracts requires more than technical infrastructure. Fragmented, non-standard, and siloed data sources remain among the most significant barriers to building the single source of truth needed to drive improved outcomes and operational efficiency. In Edifecs' latest blog, Michael Pattwell and Elle Phillips examine three common pitfalls payers and providers face on their VBP journey and share practical solutions to address them: 🔹 System fragmentation across five, ten, or more platforms with unique data structures and coding conventions creates semantic differences that lead to confusion and errors even when technical interoperability is achieved. 🔹 Social determinants of health account for 80% or more of outcomes, yet many VBP models still focus narrowly on clinical metrics, missing the opportunity to address factors like food insecurity, housing, and transportation. 🔹 AI and machine learning can identify high-risk patients earlier and enable targeted interventions, but adoption remains uneven given regulatory scrutiny and the need for transparency. Read the full blog: https://bit.ly/4f9EDcW

An often overlooked benefit of investing in FHIR is the ability to support more effective data privacy controls through granular, computable consent management. Kevin Day discusses the enterprise benefits in this blog post.

Honored to be featured in HealthcareITtoday alongside some brilliant minds tackling one of healthcare's most persistent challenges - payer-provider integration. My take: the barriers aren't just technical. They're structural. Direct API-to-API communication between payer systems and provider EMRs remains limited, and even when these systems do connect, the underlying data models and workflows often aren't aligned. What should be "standard" exchanges in theory can behave very differently in reality. Add in clearinghouses, proprietary networks, and vendor-specific gateways — and you've introduced extra translation layers, fees, and opacity that slow everything down. The path forward? Broader adoption of HL7 FHIR + SMART-on-FHIR, payer-facing interoperability gateways, and regulatory momentum like the CMS Interoperability and Prior Authorization rules. Real-time, standards-based exchange - less fax, less manual, more transparent. The industry is moving in the right direction. As organizations increasingly adopt standardized, API-driven exchange, the administrative burden will follow - down. Thank you to the Healthcare IT Today team for including my perspective! #Interoperability #HealthcareIT #PayerProvider #FHIR #HealthIT #DigitalHealth #DataStandardization #Cotiviti #HealthcareInnovation https://lnkd.in/eA-6ren5

CMS has finalized national HIPAA standards for healthcare claims attachments and electronic signatures under CMS-0053-F, requiring payers and providers to move away from fax and mail-based processes by May 2028. VP of Product Management Maxim Abramsky breaks down what the rule means in practice. Providers will submit claims attachments digitally using standardized formats, clinical records will be exchanged in a common digital language through HL7 CDA, and digital signatures will replace wet signatures to verify authenticity. CMS estimates the change will save the healthcare industry roughly $782 million annually. Prior authorization attachment standards are not yet finalized, and HHS will continue to evaluate alternative standards currently being tested by industry. For health plans, the rule is an opportunity to modernize claims operations across four key areas: intelligent attachment correlation, lifecycle visibility through comprehensive dashboards, streamlined provider collaboration, and workflow automation. Read the blog: https://hubs.ly/Q04c39c30

CMS-0057-F is moving the healthcare industry from interoperability planning into implementation, public reporting, and measurable outcomes. For payers and their technology partners, the focus now is on operationalizing mandate-driven investments to deliver real-world benefits. At the WEDI Spring 2026 Virtual Conference, Edifecs, a Cotiviti business, will showcase how its enhanced interoperability platform, including a unified prior authorization solution, can help health plans realize the true value of their interoperability investments. Join us at the virtual booth and these upcoming sessions: 🔹 Interpreting Public Prior Authorization Metrics, Tuesday, May 12, 11:15 am ET Learn what early public prior authorization metrics reveal, how FHIR transaction data provides deeper insight, and which next-generation metrics can help quantify ROI and reduce burden. 🔹 Quick Wins for Prior Authorization Efficiency, Wednesday, May 13, 11:30 am ET. See how organizations can harmonize prior authorization intake, apply intelligent routing, automate routine decisions, and integrate FHIR-based workflows with existing systems. https://bit.ly/3QLkwYc

Edifecs is joining the WEDI Spring 2026 Virtual Conference to help health plans move from CMS-0057-F readiness to operational reality. Stop by the Edifecs virtual booth to explore strategies and tools to translate interoperability mandates into scalable workflows, enable FHIR-based exchange across prior authorization and member consent, and move beyond compliance to measurable outcomes. Add these sessions to your calendar: 🔹 Interpreting Public Prior Authorization Metrics, Tuesday, May 12, 11:15 am ET. Learn what early public prior authorization metrics reveal, how FHIR transaction data provides deeper insight, and which next-generation metrics can help quantify ROI and reduce burden. 🔹 Quick Wins for Prior Authorization Efficiency, Wednesday, May 13, 11:30 am ET. See how organizations can harmonize prior authorization intake, apply intelligent routing, automate routine decisions, and integrate FHIR-based workflows with existing systems. Register for the WEDI Spring 2026 Virtual Conference: https://bit.ly/3QLkwYc

Edifecs and Cotiviti are ready for you here at the National Association of ACOs (NAACOS) Spring 2026 Conference in Baltimore! Stop by and learn how we empower ACOs to navigate the latest CMS regulations, supporting first- and second‑level coding review to identify and assess risk‑adjustment gaps. We'll see you soon!