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EHR Access for Payers? How (and When!) to Cooperate


In healthcare, safeguarding patients’ protected health information (PHI) is one of the most carefully followed rules, second only to behind “First, Do No Harm.” Hospitals, physician practices and providers understand their obligation to protect patients’ privacy at all costs. Much like any industry, the digitalization of health information has complicated the issues of privacy and data security for all parties.

Since the introduction of electronic medical records, the benefits of sharing health information across healthcare partners has become an increasing topic of conversation. Dubbed as health information exchange (HIE), sharing clinical information in real-time has been promoted for its ability to reduce medical errors, eliminate duplicate/unnecessary services, and improve efficiency. For clinicians, the benefits are clear, but increasingly, payers are making the case for gaining access to HIEs across the country. Payers claim they can use EHR data to facilitate faster processing of claims, audits and HEDIS reviews.

Fortunately, providers and health systems have a choice in deciding when and how they provide EHR data with payers – and understanding the pros and cons of doing so should be a critical element of the decision-making process.

What’s In It For Payers?

First, understanding why payers really want this information is important. We’re all in business to do better and improve operations, and payers are no different. There are a number of benefits payers could reap from being granted full EHR access. The first and most obvious is – it makes their jobs easier. Processing claims with full access to medical record data can significantly speed up the process, saving payers significant resources required to track down supporting information from health systems and providers. Secondly, EHR information can be used during the retrospective auditing process – which can help payers recoup overpayments made to providers. Similarly, it can be used in the risk adjustment/HEDIS review process, which in many cases can help payers demonstrate to CMS that their member pools are lower risk and lower cost – which also comes with significant financial benefits for the payer.

Making it Work for Providers

As providers, maintaining a positive working relationship with payer partners is important. While some systems may be hesitant to grant EHR access to payers, there is a way to cooperate while also safeguarding your patients’ privacy and focusing on your organization’s best interests.

Here are a few tips for any provider considering sharing EHR data:

  • Consider restricting access. Rather than providing full, automated access to EHR data, a manual process for sharing specific elements of the record may be the best option. This can help improve efficiency for both parties, while also helping you protect yourself from security/privacy concerns and/or lost revenue.
  • Get meaningful consent from your patients. If you choose to share information with payers, be sure your patients know and understand what you’re doing and why. While you can use an opt-in or an opt-out methodology for getting consent, make sure it’s more than a check-box exercise – it’s the right thing to do and may help you avoid headaches in the future.
  • Engage your data security team. The digital sharing of any information can put your organization at risk for a data breach. Be sure your data security team is engaged in the process – they will want to be a part of the discussion and to understand how the payer will protect your patients’ medical and personal information.
  • Share in the financial upside. Sharing EHR data for HEDIS/risk adjustment reviews could help payers earn millions of dollars from CMS. Negotiate to get a percentage of these financial benefits for your organization as part of your payer contract.

Working together, partnering with payers and patients to achieve efficiencies can help improve operations and reduce healthcare costs over time. With that said, putting your patients and your organization’s best interests first, take careful consideration before sharing EHR data with your payer partners.

GeBBS Healthcare Solutions is committed to supporting health information management (HIM) professionals with a whole suite of HIM solutions. To learn more, visit gebbs.com.

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