The evolution of value-based care has presented new opportunities for payer-provider collaboration, allowing them to redefine their partnership based on shared incentives. Collaborative efforts between payers and providers are particularly important for Medicare Advantage Plans, Managed Medicaid, Special Needs Plans (I-SNP, D-SNP, C-SNP), and Accountable Care Organizations (ACOs). These collaborations include sharing clinical data, facilitating care management, and care gap closure to optimize Medicare and Medicaid reimbursements, improving patient outcomes, and reducing costs. As growth in shared risk and incentives continue and trust between payers and providers grows, collaboration can help to transform historical friction points such as claims processing, prior authorizations, enrollments, and more.
1Clearsense™ Data Analytics & Interoperability Platform
CMS is further influencing collaborative data sharing through regulation. The Cures Act (2016), CMS Interoperability and Patient Access Final Rule (2020), No Surprises Act (2022), and now the upcoming CMS proposed rule for 2026 have increasingly prioritized healthcare data interoperability nationally. Healthcare data standards, including HL7, X12, FHIR, CCDA, and USCDI, are more important than ever. These standards further enable data exchange and accelerate the use of shared data in cost transparency, risk adjustment, quality measures, utilization management, care coordination, and other use cases. Payer-Provider collaboration is essential for value-based care.
The Clearsense Approach
As an all-in-one healthcare data platform, 1Clearsense treats databases and message types as Data Sources. These sources are ingested and mapped into the Clearsense Healthcare Data Model, which offers accelerators for quick implementation of connections, mapping, and data quality rules. It retains data lineage and traceability while allowing for granular data access policies and security controls. Payer and provider data can reside within the common healthcare data model, supporting source of truth determination and trust rule assignment. Accessible data can be used in Clearsense analytics, outgoing integrations, and customer-specific applications through 1Clearsense's bring-your-own-tool (BYOT) capabilities.
How Clearsense Helps
- Enable robust data-sharing transactions, including ADT messages, CCDs, and claims.
- Support sharing data in standard formats and ontologies, including USCDI, FHIR, and X12, regardless of whether data is originally shared in those formats or accessed through point-to-point connections.
- Facilitate deployment of interoperable transactions with automated business rules and workflows to streamline the processing between payers and providers and reduce the need for manual interventions.
- Aggregate diverse patient and member data into unified domains for analysis, insights, and visualizations of healthcare needs, outcomes, and behavioral patterns.
- Analyze utilization, cost, quality, and risk, in developing visualizations and advanced analytics.
Payer-Provider Collaboration Benefits
Reduce manual transaction processing activities in requesting, receiving, reviewing, and processing claims and itemized bills for adjudication and data exchange.
Improve claims adjudication accuracy for optimal claim submission and CMS reimbursement.
Enhance quality measure reporting, accuracy of risk adjustment, care gap closure, and optimize value-based care reporting.
Shorten critical member and patient follow-up times for improved outcomes.
Streamline transitions of care and enhance care coordination to lower readmission risk.
Why Payers and Payviders Choose Clearsense
Data Aggregator
Facilitating the seamless and transparent exchange of information between healthcare providers and payers in compliance with NCQA DAV certification.
Robust Interoperability
HL7 and FHIR-enabled platform supporting common healthcare messages and transaction types, including CCD, ADT messages, and claims, following healthcare standards, including USCDI and EDI X12.
Velocity and Agility
Leveraging the Clearsense Healthcare Data Model, 1Clearsense scales to accommodate your organizational growth and rapidly responds to market demands with unmatched velocity.
