How Interoperability is Breaking Down Healthcare Barriers with Elaina McMillan Edifecs

Elaina McMillan, a director of product marketing at Edifecs,  describes the challenges and opportunities around healthcare data interoperability with a focus on prior authorization. Standardizing prior authorization workflows and data submissions across payers is a major focus to reduce delays and errors. Ensuring data security and patient consent are critical concerns, especially for smaller payers with limited resources to comply with mandates.

 Elaina explains, "Primarily, what I work on and what Edifecs is most known for is our healthcare data interoperability platform, which includes EDI standards and the new-ish since 2020 FHIR standards. So we're really focused on that. How I would explain it is the data engine that helps payers get things done with quality data through the standardization of that. In addition, we have a whole set of what we call workflow solutions or applications that you can actually build on top of the data platform. So it helps to do things like claims correction, enrollment management, value-based payments, risk adjustment, prior authorization, and consent management."  

"So the one that actually comes to mind for me right now, and largely that's because of the recent interoperability and prior authorization mandate, is the prior authorization workflow. A lot of providers don't like the workflow itself and the prior authorizations. What happens today generally is that providers are contracted with a lot of different payers. All of these payers have their own systems and processes through which the provider needs to submit. So one problem is that the providers are managing multiple different workflows, processes, platforms, and technologies."

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