Each year, KLAS celebrates the successful payer, provider, and vendor partnerships that are enhancing healthcare outcomes with the Points of Light awards. In 2025, the five main challenges addressed among the 25 case studies are value-based care, prior authorization and utilization management, network management and patient registration, payer-to-payer data sharing, and payment efficiency and data access. For ease of reference, the rest of this blog is organized by those five challenges. However, it is important to note that within these areas, all collaborations but one also had an aspect of interoperability or clinical data exchange.
Read on to learn more about each case study’s specific situation and what the partnerships did to address the challenges. For a quick look at the outcomes of each one and to learn more about the overall learnings from the Points of Light, we encourage readers to look at the Points of Light 2025 overview. For more complete details about each case study, please check out the links below.
Three of the below case studies earned the 2025 Peak Award. Winners were decided at our recent 2025 K2 Collaborative Payer/Provider Summit, where attendees vote for the collaborations they view to have the most impact.
Value-Based Care Challenges
Case Study 2: Implementing Real-Time Data Exchange to Ensure Timely Care
- Healthcare Organization 2 is an in-home health assessment organization that historically used a weekly data exchange process to send member data to Humana. This process led to inefficiencies and delayed care for the payer’s members. Building on a previously established API, the stakeholders created a FHIR API called Clinical Data Exchange, which enables the healthcare organization to send member data to Humana in real time. Outcomes include improved data accuracy, improved efficiency, and better health outcomes.
- Providing timely post-discharge care to at-risk patients is a national challenge that can result in suboptimal care, costly readmissions, and avoidable acute care episodes. Working with InterSystems’ interoperability tools, Healthfirst (a provider-sponsored health plan) began using clinical data from near real-time HIE feeds to pinpoint members with a qualifying event for a time-sensitive HEDIS measure. The tools then send automated alerts to clinicians, giving them enough time to schedule follow-up care. Healthcare Organizations 4-1 and 4-2 also worked with Healthfirst to refine workflows and processes, enabling quick action on the alerts. Results include improved performance with targeted HEDIS measures and a lighter administrative burden.
- Praxis Health needed timely patient data to improve their value-based care program and decrease costs. Regence partnered with Cedar Gate Technologies to develop a user-friendly value-based care analytics program for their healthcare partners, including Praxis. All stakeholders prioritized training for the solution. Outcomes include enhanced data sharing, decreased claims-processing lag, and improved provider quality metrics.
Case Study 8: Automating Secure Release of Information for Quality & Risk Adjustment Use Cases
- The payer organizations in this collaboration struggled to access patient data in a timely manner to determine risk scores and meet quality measures. Historically, the payer organizations sent requests for medical records to Healthcare Organization 8 at a specific time of year, which then overwhelmed that organization. To improve these challenges, the stakeholders collaborated with Moxe Health and Cotiviti to automate the release of information (ROI). Outcomes include a more efficient ROI process and time savings for all.
Case Study 12: Improving CMS Star Ratings Through a Robust Patient Experience Program
- After changes to the CMS Star program, Elevance Health struggled to improve their Star Rating related to member experience. Collaborating with Press Ganey, they assessed the quality of the patient experience at several healthcare organizations (including Providence Clinical Network). They then supported those organizations in improving. The stakeholders increased their rating for the patient/member experience Star metric, improving care quality, increasing reimbursements, and increasing member retention.
Case Study 13: Advancing Health Equity & Clinical Care Through Standardized SDOH Data Exchange
- Stakeholders in this case study needed a standardized approach for exchanging social determinants of health (SDOH) data to improve care coordination and patient outcomes. Epic, Rush University Medical Center, and Humana collaborated to build a data infrastructure that flowed into the clinical workflow at the point of care. This reduced the administrative burden and increased visibility of patients’ social needs, ultimately improving patient care.
Case Study 14: Increasing HEDIS Rates with an NLP-Driven Prospective Review Process
- All stakeholders in this case study wanted to improve the accuracy of HEDIS reporting as well as the HEDIS quality rates for key populations. Astrata worked with Capital District Physicians’ Health Plan (CDPHP) and Community Care Physicians (and other healthcare organizations) to build an NLP software that extracts needed data from clinical notes, easing the documentation burden. Stakeholders maintained continual alignment throughout the process. As a result, HEDIS quality measures improved and the speed of getting HEDIS reports increased, while still maintaining high report accuracy.
- Kell Medical and Humana felt burdened by time-consuming, manual processes for reporting care gaps that inhibited provider engagement. High administrative costs and documentation burden led to challenges in maintaining high care quality and poor access to patient information. Humana worked with Availity to develop two reporting tools that would digitize the process and also prioritized provider awareness of the tool and engagement in its use. As a result, provider engagement substantially increased, and care gaps are closed more efficiently.
Case Study 17: Closing Care Gaps & Reducing the Administrative Burden Through Improved Data Sharing
- Healthcare organizations often struggle to access insights at the point of care that would enable them to close patients’ care gaps. In this collaboration, Your Health and Humana partnered with athenahealth to address this challenge by implementing athenahealth’s tool for care and diagnosis gaps. Since implementing the tool, the stakeholders have improved the quality of patient care and reduced the administrative burden.
Case Study 18: Optimizing Value-Based Care by Delivering Insights at the Point of Care
- Healthcare Organization 18’s process for pulling the data needed to close quality care gaps was inefficient. Their clinicians had to spend a significant amount of time searching for the data, leading to increased burnout. To help combat this, Humana and Veradigm integrated alerts into the healthcare organization’s EHR to improve clinical decision support. This has resulted in reduced clinician burnout and improved patient care.
Case Study 21: Using EHR-Agnostic Point-of-Care Alerts to Improve Care Gap Closure & Risk Scores
- Healthcare organizations using small or niche EHRs were struggling to receive timely, actionable payer data so that they could deliver quality care and close care gaps. To solve this challenge, Humana partnered with Vim to digitize data exchange and data capture. This partnership resulted in risk adjustment and quality alerts being delivered to clinicians’ point-of-care workflows, enabling them to deliver better care.
Case Study 23: Relieving Financial Pressures & Increasing Member Engagement Using Machine Learning
- Payer Organization 23 wanted to engage Medicare-Medicaid Plan (MMP) members who had been unengaged in their health to decrease costs and improve clinical care. They also needed accurate risk adjustment and CMS metrics to receive higher CMS reimbursements. But identifying and prioritizing the right members required a lot of time and manual processes that made it hard for both Payer Organization 23 and Healthcare Organization 23. So, they partnered with N1 health and automated the process using an AI offering. From there, they optimized outreach by identifying the members most likely to engage and the most effective methods of care, thus increasing member engagement and CMS reimbursements through adjusted HCC scores.
Prior Authorization & Utilization Management Challenges
Case Study 1: Leveraging Innovative Technology to Streamline Medication Prior Authorizations
- The process of obtaining prior authorization for specific medications can be very inefficient, adding to an already heavy workload for physicians and staff. So, to improve efficiency in this study, the collaborators created innovative capabilities that helped automate the submission and approval process for select drugs. This technology led to faster approvals, fewer denials, and reduced physician abandonment rates, all which result in improved patient access to their medications.
- A healthcare organization was manually submitting clinical information for concurrent review, which delayed their payer’s decisions. To improve the process, the stakeholders partnered with Epic to implement Payer Platform. Using this solution enables the healthcare organization to send information to the payer in near real-time. This helped to reduce the administrative burden and improve care access for patients.
- Payer organizations sometimes need to request charts from hospitals to get the needed clinical evidence for inpatient diagnosis-related group (DRG) claims processing. To speed up the process for these claims, Aetna used Epic Payer Platform to connect to health systems and built a FHIR-enabled data repository for member clinical data. Working with OSF Healthcare, the parties were able to decrease chart requests and turnaround times for claims reviews. The result: faster decisions, fewer delays, and greater efficiency.
- Facing frustrating inefficient processes in utilization management, Payer Organization 10 and Allegheny Health Network partnered with enGen to create a two-phased plan to make it easier to receive authorizations. Each partner worked to stay aligned through the project and made training for clinical staff a priority. This approach led to a decreased administrative burden and helped Allegheny’s workflows to stay compliant.
Case Study 11: Automating Prior Authorization via a Networked FHIR Service
**2025 Peak Award Winner**
- To support the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), eHealth Exchange worked with several payer and healthcare organizations in developing a networked FHIR service. This network enables seamless data exchange through a single connection, something that will significantly streamline trusted exchange.
Case Study 16: Streamlining Prior Authorization Through Epic Payer Platform eMPA
**2025 Peak Award Winner**
- Ballad Health struggled to manage their prior authorization process and lacked resources to invest in helpful technology. Ensemble and UnitedHealthcare helped the organization to implement Epic’s electronic medical prior authorization tool. This solution led to significant reductions in the time spent on prior authorizations.
Case Study 24: Reducing Administrative Burden & Time to Care Through Touchless Prior Authorization
- Manual processes and system misalignment slowed prior authorizations between Medical Mutual of Ohio and OSU Wexner Medical Center. With Rhyme as a third-party facilitator between them, the parties developed an automated prior authorization process. As the stakeholders collaborated to align their goals and outcomes, the partnership led to reduced decision times, cost savings, and increased approval rates.
- Prior authorization processes at Healthcare Organization 25 created an administrative burden on office staff and delayed patient care. To find solutions, Healthcare Organization 25 and Payer Organization 25 partnered with two vendors: HealthHelp, a WNS company, for utilization management and with Anterior for AI. Their collaborative, AI-driven solution led to a 99% reduction in approval time and delivered high clinical accuracy and cost savings.
Network Management & Patient Registration Challenges
Case Study 6: Streamlining Referrals Through an API-Driven Provider Directory
- Pikeville Medical Center faced challenges referring patients to in-network specialists due to limited data access and inefficient workflows. To address this, Humana and Epic piloted an API-driven provider directory at Pikeville. The solution saw improved referral accuracy, reduced administrative burdens, and boosted patient health outcomes and engagement.
**2025 Peak Award Winner**
- Manual patient registration at Healthcare Organization 7 contributed to insurance errors and was time consuming. Together with Humana, Epic, and the CARIN Alliance, they created programs within Epic Payer Platform to access coverage information and digital insurance cards. These programs enabled the healthcare organization to access insurance information directly from the payer, thus reducing registration times.
- Maintaining accurate provider directories is critical but often labor-intensive. HiLabs created a solution using a proprietary large language model (LLM) to automate maintenance. All stakeholders in this study promoted alignment and training to aid adoption. Outcomes include more accurate directories, increased data exchange, and savings on administrative work.
Payer-to-Payer Data Sharing Challenges
Case Study 19: Using a Hub-and—Spoke Solution to Enhance Payer-to-Payer Data Exchange
- To meet CMS’s 2027 mandate for payer-to-payer data sharing, Payer Organization 19 and Humana partnered to fund a hub-and-spoke architecture developed by Availity.The stakeholders were then able to standardize data exchange between themselves, which lays the groundwork for potential long-term cost savings.
Payment Efficiency & Data Access Challenges
- In this study, Payer Organization 22 and Healthcare Organization 22 faced inefficiencies in their healthcare payments processes. Portions of payments were sent via paper checks to Healthcare Organization 22 and other organizations, leading to delays in payments, errors, increased exposure to fraud, and friction. The payer partnered with Zelis, to implement a single electronic payment solution. This not only accelerated payment delivery, it reduced the friction and costs, increased collaboration, and enhanced operational efficiency and patient care.
© Lyndon S/peopleimage.com / Adobe Stock
