Enhancing Healthcare Interoperability with Intelligent Health Market as a Service (IHMaaS)

Challenge

The healthcare ecosystem faces significant challenges in achieving seamless integration between payers and provider networks. For payers, connecting with provider networks and health solutions partners has historically been a labor-intensive and manual process. This complexity is further exacerbated by the need to identify the optimal combination of health solutions partners, such as provider networks, pharmacy benefit managers (PBMs), and specialty networks, while navigating fragmented data systems.

Key challenges include:

• Fragmentation: A lack of interoperability between disparate technologies complicates data sharing and integration.

• Data Normalization: Ensuring that data from diverse systems can be standardized into a single usable dataset.

• Compliance and Security: Managing sensitive personal health information (PHI) and personally identifiable information (PII) while adhering to regulations like HIPAA and SOX.

• Administrative Costs: High costs associated with manual processes and onboarding new partners.

• Market Insight: A limited ability to perform unbiased, data-driven evaluations tailored to the unique needs of patient populations.

The overarching goal was to deliver high-quality, cost-effective healthcare while reducing inefficiencies and enabling payers to better serve their member populations.

Solution

To address these challenges, the Intelligent Health Market as a Service (IHMaaS) solution was introduced. The IHMaaS platform empowers payers to optimize and seamlessly connect with their ecosystem of providers, networks, and health solutions partners through a single integrated platform. This creates efficiencies for buyers and unlocks new revenue opportunities for sellers.

Business Solution

• Optimize: Reduce healthcare costs with data-driven network and pricing optimization, identifying strategic purchasing opportunities through advanced analytics.

• Connect: Enable scalable interoperability and real-time data exchange with a centralized hub for payers, providers, and healthcare organizations.

• Grow: Accelerate membership growth and expand business opportunities for providers and networks through operational efficiency and optimized connections.

• Comply: Stay ahead of regulatory changes like Price Transparency and the No Surprises Act, reducing compliance risks.

Technical Solution

The MiX platform serves as the technological foundation of IHMaaS:

• Marketplace Power: Identifies optimal provider networks and health solutions partners tailored to specific member populations, enabling payers to design solutions that make care more accessible and affordable.

• Customizable Components: Built with customizable, visually intuitive components to empower end users, such as EDI analysts.

• Data Standardization: Normalizes diverse datasets into a unified format, supporting seamless integration and analytics.

• Compliance Integration: Adheres to ANSI X12 standards for EDI transactions and ensures HIPAA and SOX compliance.

By leveraging the MiX platform, payers gain a comprehensive view of real-time data, intelligence, and transparent pricing, unlocking increased performance and better outcomes.

Outcome

The IHMaaS solution delivered measurable value to both payers and provider networks:

For Payers

• Access and Purchasing Power: Enhanced access to provider networks with greater purchasing power.

• Data-Driven Market Evaluation: Impartial, data-based assessments tailored to patient needs.

• Administrative Efficiency: Reduced administrative costs through streamlined processes.

• Regulatory Compliance: Full adherence to evolving regulations, reducing compliance risks.

• Analytical Capabilities: Advanced tools to analyze data and uncover actionable insights.

• Comprehensive View: A broader perspective on strategic opportunities within the healthcare ecosystem.

For Provider Networks

• New Opportunities: Increased connections with payers, unlocking revenue growth.

• Streamlined Integration: Standardized data sets and unified connections.

• Cost Reductions: Lower activation and administrative costs for new payers.

• Analytics-Driven Decisions: Advanced analytics to drive strategic planning and decisions.

• Regulatory Compliance: Ensuring smooth operations and adherence to standards.

Key Metrics

• 2.5 million commercial clients served.

• 16% average reduction in clients' annual healthcare spend.

• $1.7 billion+ in annual healthcare transaction value.

• 47.6% average savings reduction from billed charges.

Santex’s Contribution

The Santex team played a critical role in the success of the IHMaaS solution:

• Client Onboarding: Managed the activation of new clients on the platform, enabling seamless integration with provider networks.

• Historical Data Processing: Identified efficiencies and opportunities for new revenue streams through advanced data processing.

• Technical Leadership: Provided leadership and introduced agile development best practices.

• Scalable Growth: Expanded the team from two developers to over 20 experts specializing in integrations, migrations, automated/manual testing, and support.

• Key Achievements: Supported the evolution of three product versions for client integrations; Implemented ETL processes aligned with ANSI X12 EDI standards; Ensured HIPAA and SOX compliance.

Through these efforts, Santex contributed to a transformative solution that enables payers and providers to deliver cost-effective, high-quality healthcare while driving efficiencies and growth across the ecosystem.