How Payers Unlock Healthcare Efficiency Through the Power of APIs

September 20, 2023 - Today’s healthcare consumers expect a seamless experience from a trusted source, and APIs facilitate this without imposing burdensome operational and technical challenges for payers. For health plans to meet members where they are, they require real-time, secure, and reliable data, along with technology integrations from trusted partners to streamline internal operations.

Even before the pandemic ushered in a rapid wave of digital transformation across the healthcare industry, McKinsey experts warned that payers were running the risk of falling behind their competitors without investing time and resources into strategizing and developing a modern digital health ecosystem to improve member experience, provider relations, and internal operations.

According to Gartner’s most recent analysis of real-time health system technologies, APIs will play a crucial role in the healthcare industry’s goal of achieving interoperability and robust health data exchange and a cornerstone of any successful digital transformation strategy in light of federal mandates to connect the healthcare system. Furthermore, tapping into the API expertise and marketplaces offered by technology partners will enable healthcare organizations, including payers, to avoid pitfalls along their path to digital maturity.

Given that critical healthcare data remains scattered across various systems, APIs can play a central role for payers to turn volumes of data into actionable information and services for their members, providers, and internal staff by making the health plan operations more interoperable and the member experience more personalized, affordable, and accessible.

The time is ripe for action based on the growth of the API market and its role in digital transformation efforts across all industries. A 2022 study by 451 Research found the average number of APIs used by participating enterprises amounts to 15,564. Large enterprises with over 10,000 employees exhibit an even higher reliance, with an average of 25,592 APIs currently integrated into their systems. Likewise, recent data show API integration has become a top priority for the vast majority of companies and is increasingly essential to an average of more than two-thirds of an organization’s revenue.

As the overall digital ecosystem evolves, developers are likewise adapting and embracing APIs in various capacities. Internal APIs have gained significant traction, with 75% of developers utilizing them to enhance their workflow as of 2022. However, the most striking shift is the embrace of third-party API, with 54% of developers harnessing these external APIs in 2022 (a 5% increase over the previous year).

For payers that prioritize the needs of their members, providers, and internal staff, it is critical to capitalize on the potential of APIs to provide the necessary clarity, confidence, and guidance.

“For health plans, their brand and experience are their market strength. A consistent look and feel are critical for clarity and building trust with members and employers. The best way to ensure consistent experience is to take advantage of the APIs of their trusted partners to extend their capabilities for members while not disrupting their experience.” says Zelis Vice President of Enterprise Enablement, Matt Zelehowsky.

“When the language in the Explanation of Benefits document matches the details in the automated updates in the call center interactive voice response, it builds trust. When the cost estimation insight is aligned across the digital and print Member experience, it brings confidence. Having that consistent, repeatable, secure experience is also powerful for providers and health plan associates.”

To manage and expand their digital health ecosystems, more and more payers are looking to strategic technology partners with API-enabled turnkey solutions that enable differentiated services in the market, as well as internal operational efficiencies.

“Standardized API and API-related processes allow health plans to plug and play to deliver a seamless experience for all of their constituents and offer payers a straightforward opportunity to expand their offerings,” Zelehowsky explains. “Real-time data and services are made readily available to the health plans to address the needs of their stakeholders.”

At the same time, payers are able to maintain control and set the pace, Zelehowsky adds. And the benefits aren’t restricted to member-facing activities.

Internally, operational gains are within reach. For instance, health plans can make sure explanations of benefits (EOBs) are visible within their claims administration system so when staff are on the phone with a member, this information is close at hand.

“Even though the EOB just went in the mail two days ago, staff can see what was actually in the mail so customer service can provide members with assurance that their end-to-end experience as a member is visible,” says Zelehowsky.

An API-enabled digital health ecosystem also improves provider relationships.

“The most frequent inquiries from the health plan’s standpoint come from providers seeking information about the progress of their claims or the location of their checks,” Zelehowsky notes. “APIs and data access mean providers can get answers based on their preferences — in print, digitally, or directly in their operational systems for claims, customer support, and the like. They no longer need to wait for the bank to finalize and execute the payment. This real-time insight greatly streamlines communication and eliminates unnecessary delays.”

Health plans must embrace APIs to meet evolving healthcare demands and market trends. With the help of a trusted strategic partner, health plans are empowered to unlock an integrated experience and reduce operational pain points.

Choosing the right strategic technology partner is crucial. Access to a high-quality API marketplace enhances efficiency and improves user experiences by making useful interfaces and tool kits available to drive strategic growth and innovation. A partner that simplifies API development, management, performance, and security through standardized practices will provide the most significant benefits to both developers and end-users.

APIs offer a way to transform data into valuable services, improve stakeholder experiences, and streamline operations. And the right strategic technology partner offers the straightest path forward to ROI.

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To learn more about the role of APIs in healthcare and how you can take advantage of them to extend your capabilities, click here to download “The Role of APIs in Transforming Healthcare” whitepaper.