Healthcare API: Everything TPAs Need to Know

Healthcare APIs Blog Post

Intro to Healthcare APIs for TPAs

A healthcare application programming interface (healthcare API) allows information systems to exchange healthcare data in a more streamlined and effective way. In recent years, APIs have played an even more important role in healthcare, improving data accessibility for patients, physicians, and payers. APIs have huge potential for benefits administration. As these systems continue to advance and gain widespread adoption, it’s important for third party administrators (TPAs) to stay informed.

As a creator of innovative data solutions for TPAs, we’ve recently broken down everything you need to know about HL7 FHIR, a healthcare data standard that includes specifications for APIs. In this TPA Trends article, we’ve explored everything TPAs should know about APIs, the beneficial impacts they offer, and how they may change the healthcare data landscape in the years to come.

Importance of Healthcare APIs in the Benefits Industry

Healthcare APIs promote greater accessibility and ease of data exchange: patient, physician, and benefits provider. In outdated systems, valuable healthcare data was locked away and inaccessible, making it difficult for parties to stay informed about key healthcare data and stalling the process of accessing data when making decisions. Streamlined data exchange allows for better decision-making based on more comprehensive, real-time data. For the benefits industry, this empowers the creation of better benefits plans and streamlines the process of claims collection, an essential part of benefits administration. 

Anthem, the largest for-profit insurance provider serving more than 43 million Americans, recognizes the power APIs hold to simplify and better the healthcare industry and data exchange experience. Earlier this year, we announced that Anthem plan members now can enjoy faster and more accurate claims payment when their third party administrator uses TPA Stream. 

“Anthem’s decision to extend the API to all members demonstrates their commitment to making Patient Access a reality for all members. The addition of the Anthem Patient Access API further expands TPA Stream’s foothold as the leader in claims data for better benefits and marks a significant milestone for the use of health plan APIs in the benefits space overall.” 

We do expect many carriers of commercial plans to roll out a healthcare API initiative of their own and follow suit. As of December 31st, 2022, healthcare providers are required by the Office of the National Coordinator for Healthcare Information Technology (ONC) to implement HL& FHIR APIs, and the Centers for Medicare & Medicaid Services (CMS) mandate that Patient Access APIs like Anthem’s must be used by all health plans receiving funding for Medicare and Medicaid. We expect this to naturally expand to commercial plans. 

As the government pushes for further adoption and insurance providers continue to expand their API offerings, you can expect healthcare APIs to shape your benefits processes like claims processing and payment monitoring.

How You Can Use a Healthcare API for Benefits

For TPAs, a healthcare API is a vital resource for many processes. Claims data from APIs facilitate more accurate and faster claims processing. API tools make billing easily accessible and the billing process benefits from automation, reducing the time-consuming and risk-prone nature of manual entry. APIs are also useful for adjudication and informing all parties of where the claim is at in the review process. This adds greater clarity to claims processing and adjudication, empowering TPAs like you to deliver a better experience to your clients.

Healthcare APIs support your processes and allow for a streamlined approach so your operations won’t be stalled by inefficient, outdated practices. With APIs’ automation capabilities and innovative features, you will be able to spend more time delivering value to your clients with more accessible, comprehensive data for better decision-making.

Healthcare APIs also benefit medical billing apps and consumer apps. When individuals enrolled in HSA plans utilize a healthcare API, they can more easily track their balance and expenses with real time data. This allows for more conscious consumers and better informs all parties of how funds are being spent and how plans are being utilized, which empowers plan creators to base their offerings on real-time global data.

The Strategic Claims Data Choice for TPAs

Though you can expect that healthcare APIs will continue to gain traction, large-scale adoption and implementation won’t happen overnight. Many carriers who aren’t required to comply with the federal mandate will likely not offer APIs for many years. Smaller regional and specialty carriers may lack the funds or interest to invest in API technology. With this in mind, TPAs must have a way to obtain claims data through other means when working with companies that don’t utilize APIs. 

Turn to TPA Stream. Our innovative technology allows you to get all the data you need at scale. We support over 200 carriers and are moving to APIs whenever the commercial API becomes available.

Our unique solutions include:

  • Claims Harvesting – Reduce clerical work and count on the seamless, secure collection of claims files and EOBs with our tools.
  • Employer Invoicing – Effortlessly manage sales records, invoices, commission reports, and more with a single automated process that serves your unique needs. 
  • Software Development Kit – Ready to develop software requiring healthcare data? Use our toolkit so your software has a 360-view of all connected claims using our innovative API.

Healthcare API Conclusion

Healthcare APIs are going to revolutionize the healthcare industry and healthcare interoperability, but that revolution will take time. Small companies may take years to adopt it, and delays in implementation can be expected. Still, the future remains hopeful. More and more companies are making APIs available, such as Anthem, the second-largest insurance provider. APIs continue to expand and improve, and these improvements better serve all parties involved with greater data accessibility and ease of use.

Get in touch with us to learn more about how our products and API integrations can enhance your offerings and streamline your processes today.

Why TPA Stream

TPA Stream is a thriving, innovative insurance technology company committed to empowering better benefits by connecting systems, transforming data, and helping TPAs unlock more revenue.

Learn more about TPA Stream here.

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