Going Beyond Compliance to Streamline Care for Better Member Outcomes

Hello everyone, and welcome to today's webinar, Going Beyond Compliance to Streamline Care for Better Member Outcomes. We're excited. You could join us for today's session. My name is Megan Billingsley, and I'll be moderating today's event. Today we'll be talking about how evolving regulatory mandates create a new opportunity for payers. If they use these compliance requirements as a lever for strategic transformation, they can take this opportunity to implement automation and innovative solutions, making it possible to streamline operations, contain costs and improve member experience. We are thrilled to be joined by our speakers. Ghansham Kumar, IT, principal, Pharmacy Plus, Evernorth Health Services, part of the Cigna Group, Matt Petilla, Vice President, Product Development, and Jen, a subsidiary of Highmark Health, and Bill Marshall, director and industry principal for healthcare Pegasystems.

Before we get started, I have just a few housekeeping items. Please note the slides will advance automatically throughout the presentation. To enlarge the slides, click the Enlarge Slides button located in the top right corner of your presentation window. If you need technical assistance, click on the help widget located on the bottom left corner of your console. We encourage you to submit questions at any time throughout the presentation, using the Q&A widget at the bottom of your console. We will try to answer these during the webcast, but if a fuller answer is needed or we run out of time, it will be answered later via email. Please know we do capture all questions. So to kick off, I'd like to ask each of our speakers to provide a quick introduction of themselves and their work. So, would you like to go first? Sure.

Hello everyone. I'm Ghanshyam Kumar, it principal in Evernorth, a Cigna company. I have extensive experience in enterprise technology strategy and innovation almost for a decade. I am leading transformative initiatives in healthcare with streamlined operation and enhanced user experience. I am passionate about leveraging emerging Merging technologies to drive business values and a better present, better patient care. Excellent. So glad you could be here with us and Matt. Yeah. Matt Petilla, a vice president of product development here at engine, which is a subsidiary of Highmark Health based here in Pittsburgh, Pennsylvania. Uh, I manage the engineering and product development shop for predictable, which is engine's flagship clinical project product for care management and utilization management.

Uh, I've been in this role since the beginning of this year, and we're constantly working to make our care plans and our, um, processes more effective and efficient for all of our clients. Uh, prior to that, I was the chief technology officer of Highmark Healthcare, which is a Pennsylvania medicaid plan. Uh, I was in that role for about three and a half or four years before I came over to manage the, uh, the clinical team. Excellent. Thank you so much. And, Bill. Hello, everyone. I'm Bill Marshall. I'm a director and industry principal at Pega. I've actually been at Pega Systems now for 15 years. I work with our healthcare clients and have had the privilege of working with all ten of the ten largest payers in the US. Prior to joining Pega, I have been. It's an unusual career 40 years in healthcare, launching a variety of different software solutions, lines of business and even software companies.

Uh, it it requires wearing a lot of hats when you launch those things. And so I'll also mention, so, uh, you're probably wondering about the hat. I actually work remote and live on a ranch, uh, in, uh, the Shenandoah Valley in Virginia. And that may ring some bells for some of you who remember the old John Denver song Take Me Home Country Roads, in which he sang about the Blue Ridge Mountains and the Shenandoah River. And at our ranch here, we're surrounded by the Blue Ridge Mountains and the Shenandoah River. Love it. Thank you so much. So with that, then let's get right into the discussion. Just to kick us off, I'd like to ask, what kinds of shifts have you seen taking place across the regulatory landscape recently? We'll start with you. Yep. So for these regulatory changes, uh, when we see from the CMS guidelines, it is increasing expectations for healthcare organizations, data privacy and the security practices, especially after the several high profile breaches, which causes, uh, impact on healthcare organizations in 2024.

Also, requirements are coming, uh, for faster decision making and the notification for prior authorizations by 2026. All these decision must be issued within a week or within 72 hours for urgent requirements. Also, there are some flexibility for telehealth access expansion. And when we see all these CM CMS regulatory guidelines. These all are intended to improve patient experience and health outcomes. Yeah, I would jump in here and say the the prior auth mandates really open up the lid on the whole prior auth process and for very specific provider touchpoints. But if you think about it, it really benefits the patients. The persona we often think of on the payer side is the provider or the doctor. And while these mandates around prior auth definitely result in less time and frustration for them, the ultimate beneficiary of this are the patients.

So this is a mind shift that's happening. Um, this also relates to interoperability, which, you know, requires tech modernization to achieve. And it also requires us to think less transactionally and morphed from a person or patient centric point of view. You know, are we just taking in an auth request to be worked on by a, um, clinician, or are we helping to expedite a decision on what care we will enable for a patient? Uh, and quickly. And these calls for greater transparency, um, are also about more robust security, uh, as was just mentioned. These might seem at odds, uh, but this really drives us to have information and cyber security as part of the upfront design, which has many downstream benefits also. Yeah, great. Great points. CMS has really been on a kick. They have really set themselves up, I think for the at least the last five years, if not longer, really, as the consumer watchdog.

Uh, and it's a pretty admirable effort. And around that, you know, whether it's prior auth, whether it's transparency or interoperability, they're really using those as levers, uh, trying to break down the silos between healthcare information systems, between the member, the provider, and the payer. Um, and, you know, it's for admirable purposes. They're trying to improve across the entire system the burden and all that that represents around cost and burnout, etc., as well as driving better outcomes. So it it's very interesting to see it's been a fairly consistent, uh, strategy from their standpoint. The levers that they're pulling, the mandates, uh, have been, have been changing. But, uh, they clearly have been on a mission for that. The one piece that I'll add as far as what we're seeing, certainly with, uh, with the, the one big, beautiful bill, uh, that's going to have enormous revenue impact because of the Medicare, uh, membership issues there. So that's another issue that certainly, um, is staring, uh, in the face of a lot of folks in the industry that that will make, uh, make big impact. And it's certainly a big revenue driver and change. Excellent. Thank you all for sharing those insights.

I would like to ask what's driving those changes? I mean, you mentioned the big beautiful bill there. Why are regulators pushing for greater transparency, interoperability and security? So there are a lot to do with the security of the individuals. Security is important and every individual has the right to keep their healthcare information private. I think payers and providers alike are being asked to have a much closer relationship, and to share information with each other to build a holistic view of the patient, because that's ultimately what's required to achieve a cost effective, value based care outcome for those patients. There's a greater emphasis on social determinants of health across the healthcare landscape, and I don't think anyone's really cracked the code yet on how to scale the ingestion of that information and how to incorporate that into workflows or care plans. Um, and, you know, there's an increasing concern about mental and behavioral health issues as well, which requires more information on Sdoh. It's really an interconnected life cycle. Uh, and payers are in a bit of a difficult situation. On one hand, we're being asked to control costs to ensure that we can put the value back into the member benefit. But on the other hand, we're constantly being held accountable for higher denial rates, you know? So it's definitely a challenge that we have to sort out that this is really going to push us to do. Yeah, that makes a lot of sense.

Thank you. What is the checkbox mentality when it comes to compliance. And how can payers move beyond it so that they can begin to instead view compliance as a lever for strategic transformation? Bill any thoughts? Yeah, I'd love to love to speak to that. Um, you know, the checkbox mentality about it in this way. Um, too often it's it's the mindset of, well, what can we do to be compliant? Uh, so that we don't get in trouble. And that mindset is really particularly from health plans. It's it's building the minimum viable product. It's just enough to get by. And if you think about that, you're really missing out on the broader impact that some of these mandates have. And you know, I mentioned before, as far as, uh, really the strategic march that CMS has been on, it's fairly obvious with with any of these mandates that are coming up. It's it's not a one time thing. It's they're working through a whole series of things where they want to go. And it's not hard to really map that out and look at the strategy of what needs to happen. But if you've got a checkbox mentality and you're only doing the minimum, you're really actually then going to do it again the next time and again the next time. That's not cost effective and you're really not taking advantage of. realistically, uh, how that you can actually operate better at lower cost. How you can really be a care provider with and in collaboration with providers, uh, really on on behalf of your member.

So it's really short term thinking, and unfortunately, it's one that actually adds to the cost. It just doesn't look like it. Because if you're looking at budgets from a year to year standpoint, you don't see that. Uh, so it's really unfortunately, it's a very minimalistic approach. Instead of thinking strategically. You know, Bill, those are fantastic points. Um, and, you know, just to build on that a bit, if you're doing bare minimum for compliance, your MVP, as you said, it is staying out of trouble. And that's not a cost effective way to take advantage of this. And you you mentioned Bill CMS acting like a consumer watchdog. You know, and I think that's just it. Right. If we start putting the patient at the center of our design thinking and what we're building with our platforms. Instead of checking the box to avoid regulatory penalties, I think it will begin to find that that MVP doesn't make a lot of sense. Um, take the patient access rule, for example. You know, back in 2021, I was right in the thick of that, as a lot of us were. You know, we land all that patient data in a Firestore that's interoperable. But how many health plans took advantage of that to open up data channels to member portals.

Member outreach. Care plan development or even the prior auth workflows. You know, if it was good enough for our members and third parties to consume, why couldn't we then use that strategically for our own internal purposes? And, you know, I don't know how many health plans ended up doing that because that wasn't checking the box. Um, you know, and it's all these friction points around prior authorization that have been around for for decades. I see these these regulations really as being foundational from a data perspective, because if you think about it, it's about data being available for patients. It's about data being shareable from player to player. It's about data being more enriched at the prior auth point. Uh, and it's a huge strategic importance. Yet so many just, you know, check the box. Um any thoughts? Yeah. So it has a lot to do with the mindset as well. Are we using the process to be compliant or we are using compliance to re-engineer our process to improve it, to make it more mature, to make it efficient, to make it faster? And at the end, it will lead to the better patient outcome, as Matt mentioned about that, the data sharing between the, uh, different uh, uh, providers or the companies when we have the accurate data, which can support the better prior authorizations, which can support the better claim. Ultimately, it will lead to the better process outcome. It will reduce the burden from the healthcare organizations and also it will provide better patient experience at the end.

That will give you the better star rating. Excellent. I think that that's very interesting and well said. Thank you. What does turning compliance into a lever for strategic transformation actually look like from a technology perspective? Matt. Yeah, I can take that one. You know, um, if you're familiar with Conway's Law, it basically says that organizations design systems that mirror their own internal communication structure. So if the different functions within a health plan or a provider aren't talking to each other, then how great is that care going to be for the patient? And how able are the technology systems to share the data as necessary to drive that outcome? And the answer is not not very. So you know, Bill mentioned three stakeholders. You have patients providers and payers and they're interconnected points about you. You know, these regulatory changes around patient access and prior auth. You know, patients have clinical data. They have lab results, procedures, screening data. They want faster turnaround on their OS. They want faster time to receive care. And they want the claims to be paid fairly and quickly.

Providers want increased upfront knowledge about if an authorization is going to be required or not, and what they need to submit. They want speed, they want transparency, and they also have a bit of a blind spot on what the payer is doing from a care plan perspective. Payers. Payers want more holistic data sets about their patients for the CM and um workflows to drive more automation, more accuracy, less cost and time. Less requests for additional information back to the provider, which you know is a is a challenge for both the provider and payer. And payers want to know the care plan side of things, but don't have a holistic view of the patient data that the provider has in the EMR. So it's like a circle if we have all three of these stakeholders. Seeing the same information in near real time as possible to drive their workflows and their decisions, everyone's going to win. But if we if we think beyond the checkbox as we design our data architecture, our integrations and our platforms with this mindset, as Guntram put it, the patients benefit because they get care faster. Providers benefit because they spend less time getting to an off decision with less back and forth.

The payers benefit because they burn less administrative time, tracking down patient information to get the medical necessity. So literally everybody wins if we can adopt that mindset. Anything to add there? Yeah. So when we have to when we think about this security models, we need to think how to extend it across this triangle. The one Matt mentioned about the member provider and the health plan. This data needs to exchange in across this triangle for different healthcare processes, not only for the prior authorization. That will improve that the process. It will make the process more transparent. The reality is today when we do that, the data exchange, most of the time it happens through either by the phone call or the fax, not by the digital or electronic means. And when we see that the CMS guidelines on the regulatory requirements, it stipulates that the data needs to be encrypted during the exchange. That's a great point. Thank you so much. Could you maybe share an example of what this might look like in practice, say for like specific operational workflow? Bill. Sure, I'd love to. So let's take prior authorization as an example, because we've got actually some key mandates coming up on that here in about 40 days and again in a year from now. So if we look at that with what CMS is trying to do, and this is part of their interoperability and prior authorization mandate, what are they really asking for? Instead of looking at the specific mandate? What are they big picture.

What are they trying to do? Well, when you look at it, they're trying to drive greater transparency into what is a prior auth even needed for this? If yes, what are the current coverage requirements, etc.? And all of that is important because when you think about authorizations, we step back and think about this from the member's standpoint. We've got stats that show over 80% of all interactions from a member to their healthcare payer, for instance, are one of two things. Am I covered for this? And the subtlety of that question is, and if I am, how much am I going to pay out of pocket? And questions about the billing inquiry of, well, you said this was going to be covered. I don't understand why I'm being billed for this. Prior authors are at the heart of where that where that starts. So they're trying to make this more transparent, more efficient. And they're trying to guide providers into submitting much more data rich, higher quality documentation when a prior authorization authorization, excuse me, is required so that it's a fast process. Because if we're all if we think about this from our own standpoint as a patient, if we need care, the last thing we want to be waiting for is paperwork, whether that's actual paper or digital. It's an angst angst filled time. So when CMS is looking for this, they're trying to make this a very efficient process, both for the member. And again, this is that role as a consumer watchdog, but also making the system really efficient for the payers and providers, ultimately to lower cost. Uh, big part of that with prior authorization is automated automation, whether that's rules or AI.

And AI is a beautiful piece for this, but you're trying to increase the speed, make it real time. You're trying to increase the accuracy and even whether the, you know, the likelihood of a prior auth is needed, and if so, then it's approved and it's approved very rapidly. And all of this should translate into members getting the care that's needed, closing or even eliminating, uh, gaps in care from even occurring. And that actually in turn. So we look at this a lot from a cost standpoint. But one of the things that all of this improves is from the CMS star ratings, which is all about customer satisfaction. And wait times come into that, uh, decisions, yay or nay denials, etc. really negatively impact that. So the more you improve this process, the better chance you have to actually increase star ratings. That drives revenue for payers. So this isn't just a cost issue. It's not just a customer satisfaction issue. It actually drives revenue as as well. So that's one example where what the mandates are go way beyond what CMS is really trying to accomplish. Well, if I might pick up on that workflow bill and look at it from a claims perspective, you know, if we have issues with authorizations not being, uh, you know, adjudicated, uh, timely, you know, if we if we go too long and we have issues matching up the claim that's coming in to those authorizations, then we're going to have lower auto adjudication rates on claims, which is going to drive up costs for the payers.

And the other cost factor and frustration factor quite frankly, for the for the patient is going to be they're going to have to call us to understand, as you mentioned, why a claim didn't pay. So I would kind of pick up that prior auth and thread it all the way through to that, that part of the process. It's higher complexity, higher cost, uh, more calls from the patients, more frustration, um, and ultimately cost on, on both sides. And that's going to also hinder our ability to provide care. Exactly. Excellent. Thank you so much. And what about cyber security? How should payers be thinking about how to protect their data while also making it accessible to providers and even members? Yeah. So we've been talking about the three major stakeholders in this, with the patients, the providers and the and the health plan payers. And you have to think about extending security. All three need to think about security, um, extending the security across that triangle, if you will. Your data needs to be exchanged across these groups for all the purposes that we've been talking about, and not just for prior authorization, but for pretty much the whole life cycle of getting cared for for a member. And the reality is, you know, some of these some of these data exchanges, um, you know, happen in digital form, some still happen, in fact, some still happen in phone calls. But where we have digital, we're driving much more exchange of digital transactions, you know, using less facts. We want to drive down phone calls in the contact center, right. So that means more and more digital exchange of information. Um, and, you know, it's being able to encrypt all of this data.

It's being able to agree on secure endpoint protections from a cyber standpoint, how we authenticate our services to these data exchanges using industry standard encryption and, uh, authorization and access. Right. All of those things are important. You know, um, when I was at Gateway Health, we underwent a high trust certification process, which was very lengthy, but it also provided us a lot of benefit in the sense that all of those data exchanges were covered. Uh, it was a big investment, though. Um, but it was worth it. Um, but, you know, health plans, speaking from a health plan perspective, need to make that investment to, to ensure that, you know, you don't end up on the news due to a patient data breach. Yeah. Well said. Thank you for sharing those insights. How can payers maximize the value they gain from AI and smart automation over the coming months and years? Bill Well, first of all, we've got to think about how to eliminate the data silos. We've got a tremendous block of data in healthcare, but too much of it is siloed, even even within the payer communities, within the provider communities. So, you know, if you think about this, it's a long process, but you've got to have risk stratification tools. You've got to have clinical platforms, clinical data repositories, etc. but they all tend to be separated in much of what the industry does or has done to improve efficiencies has been with, with, in lines of business within departments. And while that's all been well and good, what it has created is silos. And the members and providers see that when they're trying to go through their journey.

But it even happens for staff and it causes job dissatisfaction and even burnout. But if you look at this from a holistic standpoint, holistic data centered around the member, what you realize and what's really great is that we actually already have virtually everything we need in the way of tools and data and systems at our disposal to improve the member engagements and the and the outcomes. We just haven't put those together. And this is the beauty of what we're seeing with with AI, the ability to orchestrate across really above these silos, because you can have, uh, agents that that orchestrate, for instance, for care planning. Uh, you know, we already have the data on hand, for instance, even to trigger in advance a recommendation for a next best action, uh, and even the regulatory changes that are coming along, the adoption of value based care is really trying to drive us there, where we're actually making proactive decisions. Uh, and this is where the beauty of AI comes in, because no one has to go looking for that data. You can be asking AI to really provide that information immediately and take proactive action on behalf of the member, on behalf of the payer business, on behalf of the provider. Um, the big part here is breaking down those silos. It's not that those systems don't operate well.

They just operate within really brick walls between too many different, different systems. So, you know, in this case, um, it's about connecting the dots between clinical operations, payer systems and the data. Yeah. Conway's law. Uh, that's kind of how I think about that, right? So, um, from an AI perspective, what I love about Bill's response is that, you know, data is the oxygen that AI tools, whether they be agentic or, you know, more Rag based architectures, need to breathe. You need that data is the oxygen for all of that. And you know, AI will you know, I would say it will, but it actually currently already is enabling us to build workflows, uh, both on the utilization management and authorization side, and the care and the care plan side to be able to drive down the amount of administrative time our clinicians spent. They didn't go to school to be nurses, to take time, uh, taking notes and documenting, uh, phone calls and things of that nature, or like manually looking up clinical data in this tool or that tool. You know, Bill mentioned it, your tool, you know, your clinical data repository and your and your clinical system all tend to be silos. And then they're the ones that, um, you know, suffer from that. So AI definitely helps us, um, in that regard because we're able to contextualize if we're able to auto approve an authorization leveraging AI and all the data we have, great.

If we can't, well, then why didn't it auto approve? What are the things that the, um, clinicians need to go look at? So they're not starting over, you know, what's the next best action for the, um, clinician so that they can get through more, more cases more more effectively. Um, and then with respect to when authorizations do get submitted, is it truly the right decision? And do we have good quality data to back that up? Right. Those are all things that, uh, where where AI absolutely is, is already making a difference. And I think, you know, just in general, AI is the perfect tool to expedite things like data quality, automated approvals, more contextual information, as I mentioned, because it can read fire, right? But it can also read non fire structures. A lot of the documents, you know, faxes, lab data, uh, you know, uh, data notes, medical policies, those things are all unstructured and don't work well in relational databases, but they work fantastic in AI tools. So a huge opportunity that's already starting to happen and will only increase in the future in the very near future. Uh, and I think the other thing is using AI to help us understand where our workflows are inefficient. You know, where do I have situations where our, um, and CM some clinicians, uh, are clicking a button seven times to get to a screen that they're on for five seconds.

You know, how do we start to, uh, tune tune that you wouldn't have visibility into that otherwise? Um, anything to add here? Yeah. Uh, so healthcare process in general is very complicated. When we see that the entire ecosystem, from the data exchange and from the data intake perspective, data intake, it happens from the through the different, uh, sources in different format. Now, utilizing that, the AI can easily simplify getting data from the different sources and restructuring them into the standard format to execute the entire process, uh, seamlessly. And because now, you know, we are in the day of technology where most of the applications or systems are distributed, data is staying into the different places, different sources. Collecting those data, getting those right inside and executing the process is challenging. Utilizing this AI tools, LMS or the AI's, it will make our process more mature. Once we get the data and put it through the process, evaluate it. We talked about the compliance proactively. Using this AI tools AI process. We can validate those compliance. We can validate what are the regulatory requirements, what are the need for the data validations required for the prior auth? What are the data validations required for the claim submissions? AI tools can validate it. It can mark it. Those are accurate.

Those are not accurate. If those are not accurate, it can get it from the different sources and it will make it ready available for the user to do the review. One challenge I see here is when we talk about the AI output. We have to trust what AI is generating, that output we have to trust. But at the end we have to validate it too, because several healthcare companies are facing challenges because of these lawsuits. When we are making that the wrong decision, it can impact patient. Patient life is associated with the process, the decisions. So we have to trust the AI outcome and we have to validate it. So the users spending the time to collect the data, to review the process that we can automate using that the agentic eyes, and it will reduce that the user burden to review and move the process to next stage in the end to end landscape. If you see, uh, healthcare, we have user and the process running in parallel wherever we need to collaborate between the do the collaboration between the user and the agents, we have to do it. We have to review it, and we need to continue the process in that way. It is going to make the process more efficient. It is going to make the process more transparent. When we talk about the AI, transparency is much needed. We need to know what's happening behind the scene, what data exchange is happening and how it is. Getting the data and, uh, massaging it to get it ready for the next step. And if we don't have the clarity, it's very difficult to trust on the system. So that trust we need to gain, and we have to build the process in a way that it is going to be transparent. It is for the betterment and we have to use it in the right way. I'll actually I would like to add a little bit because I love what you just said.

You know, one of the things that when we're looking at these advances in the technologies, like, like AI, we use a term called predictable AI here. And really it's particularly in healthcare or any highly mandated regulated industry, you've got to be able to tell the agents, the AI, this is how you will go about doing this work so that you can control the process and that there's a consistency and you've got to have you mentioned before, you have to have good curated data as well. And then the third piece is what we call human in the loop that as much as you turn AI loose with good instructions and with good data, the results have to be reviewed. Someone needs to see it in most cases to really adhere to the compliance mandates within healthcare. So it's an incredible tool. We're on the on the cusp of an incredible leap in productivity, but it doesn't mean people aren't involved. It means they're involved in a different way, applying their subject matter expertise, um, to to guarantee that the information is right. Uh, it just it's got to be predictable with the AI, and that requires guidance and really good data. Yeah. And one more thing, actually, I want to add here, Matt mentioned that the data is a oxygen for this whole entire AI process. Right. And when we start that, the agent and all these AI process, we do that the data cleansing.

And also we evaluate that the data biasness once the process is set up. And we started using that, the AI, it's kind of a feedback The user is working. Agents are working. What if user do a mistake and incorrect data went back to the loop? It will process over the time. So data cleansing and the accuracy is very much important. And that we can achieve by human in the loop to make sure we are adopting that the right process, we are adopting that the right SOPs and we are following it. Review is not just to see what is on the field because it's a human mentality. Once we see something accurate several times, automatically we get into that that the next thing, whatever we see that is going to be accurate. But it may not be. So when we see that the data and when we have to review it, There should be a guardrail. That is how to review it. It's not the checkbox mentality that yes, we reviewed and we moved to the next step. So that's why we need to reengineering the process to make it faster and more mature, more trustworthy. Yeah. Well said. Thank you so much. How can payers leverage this approach? Becoming more proactive, unifying data to prepare for the transition to value based care. Bill. Well, you know that transition is complex. Value based care, uh, is the outcome of a bunch of bunch of things happening in concert. And that's the whole point. It's not just I provided this service as a provider. I send in a bill, it gets gets paid. Uh, it's all about really a collaborative effort about high quality outcomes on behalf of the members. So in that realm, AI can create great efficiencies around utilization management.

It can add efficiency, quality and speed when it comes to harvesting the insights from the clinical data that we already have. And that's one of the key points here, is instead of requiring staff to go find all this information so, you know, it can really get us away from chasing after data that's in the chart, data that's in the claims review because it curates that data on behalf of. And again, that's the human in the loop, whether that's the care manager utilization manager. And that allows us to drive efficiencies in care management, which is really at the heart of looking at the outcomes that we're trying to drive for in value based care. And there's all sorts of different contracting modes for that, but they're all trying to drive towards improved outcomes rather than just what service was provided. So there's there's key questions in that. How do we leverage all of the data that we have about the members, so that their care managers really have a better view of holistic view so that they can truly drive care, eliminate gaps in care, etc.. And how do we minimize wasted effort? Uh, if we could build out capability in one area, how can we reuse it? That's another key aspect here is that there's a lot of similarities where we're actually redoing it again and again and again. And when you step, step back, you say you're actually doing the same thing. It's just nuanced by the context of that particular situation, what a particular member needs or what what you can and can't do based on where they are, what their plan is, etc. those are all just nuances, but the process should be the same or largely the same and therefore reuse.

And again that means efficiency. It means cost effectiveness. As long as you're taking into consideration the specific context, the personalization that really needs to be necessary to provide the kind of outcomes that you're looking for. And one of the last things is that when you're looking at AI agents, they can do a tremendous amount of work. But again, I'll add this again and again. Again in healthcare and any mandate, any mandated, highly regulated industry, you have to have a human in the loop to ensure accuracy. Excellent. Thank you all very much. I do see that we're almost at time. We have just a few minutes left to address some of the questions that came in from our audience. And just remember, if we don't get to your question today, we will follow up with you via email to get you an answer. So just to dive right in, Bill, I'll send this one your way first. Are there upcoming CMS deadlines, say in 2026 that payers should be planning for now? Well, yes, absolutely. In fact, it's coming up very quickly on the 1st of January in 2026. The ones that mean the most to me, there are some additional but uh, particularly for CMS, the interoperability and prior auth rule, uh, which there's there's a couple of different aspects. There's some API stuff, but the ones that mean the most uh, I think to, to most of the clients that I work with is one. There's some expedited service level agreements in which they've mandated, first of all, one that 72 hours for expedited requests around prior auth. You have to handle that in 72 hours. Uh, and then standard requests go from just 14 days now to just seven calendar days.

So both of those are coming up at the first of the year. There's more coming in 2027 as well. But those are those are critical. And that's a big change for most folks in how fast they work with their prior auth. Yeah. Well, speaking of 2027, I mean it might be one 127, but a lot of work is going to be happening in 2026. Uh, to, to hit the one 127 uh, mandate for the API portion of this, uh, rule, which is our coverage requirements discovery, uh, document template requirements, and then the prior auth submission itself, uh, all having to be in place and ready to go for one 127. Uh, you know, there are some other aspects of that implementation around the clinical decision support hooks and the clinical data exchange that were recommended to be implemented as well. I know we've done a ton of work in 25 and will continue to be ready in 2026, but that's that's a big one. Excellent. Thank you. This next one I'll send to you to start. Are there differences between how smaller or regional payers should be thinking about interoperability when they don't have the same budgets for technology transformation as national health plans? Yeah, definitely. It's a very good question. And especially when we think about the big and the small payer, uh, regulatory changes are coming very frequently. And if we don't have the right tool sets or right strategy, it's a very difficult to maintain and manage it because there are cost associated and how fast we can go to the market.

Both so small pairs when we talk about it's better to adopt the cloud, because nowadays things are easily available on the cloud, easy to integrate. And especially when we talk about the inter operability where we have to exchange that the data, there are options to adopt the vendor based product, which is already pre-made, easy to integrate, available quickly. We can integrate and we can, uh, get into the business so it can be cost efficient and faster to get into the market. So that is what my thought. Excellent. Thank you so much. Our next question asks, how can this approach help providers better manage staffing in the era of mass burnout? Matt, you want to take this? Yeah, sure. Um, you know, so when I think about our our flagship clinical product. predictable, uh, a lot of the investments that we have made have been towards automation, uh, to reduce the administrative burden on these folks who are suffering from from burnout. Um, we've been able to push our electronic prior off submission to above 80%, and we've been able to drive automation of the off determinations to over 50%. Uh, we still have work to do to continue to increase that, but that's an example of where we have just burnout within our own staff. And I think how that relates to the to the providers, I think about offs just have to be easy. They have to be easy when they when they work with us. And that's part and parcel with this regulatory shift is all about. But you know, payers aren't contributing to reducing burnout.

And the provider offices, if we're constantly coming back with requests for more information or, you know, it's confusing what needs to be submitted to get an author the system. So those are the things that we have been doing and that we need to continue to do. Um, to to avoid that, that burnout or to reduce that, that burnout. It all comes back to reducing administrative time. And Matt, I'll add, you know, it's interesting this is not just a US issue. I get a chance to work with folks in Europe and in Asia Pacific. This issue of burnout and really of losing resources because of it is actually a worldwide phenomenon, particularly around clinicians with nurses and physicians being asked to be administrators. So this is this is a huge issue worldwide. Yeah. And I think other industries, because I actually have worked in other industries and the digital transformations in those industries, um, have sort of come right at the right time, I think with healthcare, uh, if I may, I think it lagged behind a little bit. And the focus on the member centricity of the industry outpaced our ability from a technology standpoint to enable it. And so we're just playing catch up as fast as we possibly can. Thank you so much. Our next question here I'll send your way. How does the technology approach you're describing apply to pharmacy benefits management? So how I see this is it's not only the PBM but in the entire healthcare ecosystem. We have pair. We have provider. We have patient. We have PBMs.

We have pharmacists. And this interoperable ability is not just specific to the PBM. Because when we think about the data exchange, all these stakeholders needs that the right information at the right point of time. Otherwise it is going to put the delay in the process. We have to make multiple phone calls. We have to make multiple faxes. None of the prescriber are interested to get multiple faxes for the same reason. None of the payers are interested to get multiple phone calls for the same reason. So when we have the transparency in the data exchange real time, it will make the process simplified and it will give that the patient better experience. And once the patient is getting better experience, all these stakeholders will get the benefit provider. It will reduce reduce the burden from the provider payers. It will reduce the burden from the payer from the PBM. Also it will reduce the burden pharmacy. It will reduce the burden. So overall process will become more mature, more efficient because of this interoperability, operability of the process. Excellent. Thank you so much. I think we've got time for one more question. So Matt, I'll send this your way. How can payers encourage providers to participate meaningfully in data sharing when providers tech maturity varies so widely. It's a great question. It's not one that has a terribly straightforward answer, but I do think there are a few things that can occur. So number one, you know, I think the incentive needs to be there for both the payer and the provider as it relates to value based care and making sure that the member is the one. The patient is the one that benefits from all of this. Right? So there's the financial incentive aspect. I would also say, um, you know, providers can connect their, uh, their health record systems into local, uh, health information exchanges. That's a good way for providers to get data from the provider, for the payers to get data from the providers.

Uh, so that's the second angle. And then I would just say from a provider perspective, you know, going back to the API's again, tying this back to the original subject matter around, going beyond the check box, if we're going to build APIs to exchange data with providers, then let's enrich those APIs to be able to ingest more, more information, to make it easy on these providers such that they can exchange information with us without having to hire a software development shop. Um, you know, so I think it's incumbent upon the payers to help those providers in situations like that with some of the technologies that we spoke of. Excellent. Thank you so much. That is all the time that we have today. I'd like to thank our speakers, Gunjan Kumar, Matt Petilla and Bill Marshall for a great discussion today. We appreciate you sharing your insights and expertise with us in this moment of increasing health care costs and accelerating value based care adoption, it is more important than ever for payers to think differently about compliance. If they can get beyond the checkbox mentality and instead prepare for strategic transformation, they can help make healthcare more accessible, efficient and member centric, something we can all benefit from. I'd also like to thank our audience for joining us today. We hope to see you again soon. Have a great day.