Streamlining the Maze of Payer Rules: Opportunities for Technology Tools

The rapid expansion of Medicare Advantage plans—and the unique rules each plan imposes for data submission, prior authorization, and claims appeals—has created significant complexity for providers. This session explores the underlying reasons for these varying requirements and plan specific rules that create challenges as we discuss potential technology solutions that might benefit everyone. Although this discussion is led by members of the HIMSS LTPAC Committee, the topic affects everyone across the healthcare continuum. Attendees will gain insight into major challenges shared by all providers as we explore inconsistent payer policies, complex billing and coding requirements, delayed or denied payments, and the administrative burden of prior authorizations. These challenges affect operational efficiency and contribute to provider burnout. Even more, they disrupt patient care. In addition, we explore critical technology deficits that exacerbate these issues, including lack of interoperability between systems, limited automation for prior authorization processes, and inadequate real-time data exchange. As noted, we discuss potential technology solutions for challenges to help reduce administrative burden and improve outcomes. Join us for an engaging discussion on how technology, policy, and innovation can streamline administrative processes, support providers, and enhance patient care across all settings.