Key takeaways:
Epic Payer Platform connects directly with Epic’s EHR to enable real-time clinical data exchange and automated workflows between payers and providers.
Potential applications include prior authorization, care-gap closure, risk adjustment, utilization management, care management and quality-performance reporting.
Successful implementation depends on membership composition, provider participation, internal adoption, interoperability readiness, data use and alignment with the broader Epic ecosystem.
Organizations should prioritize high-impact capabilities, internal operating priorities and provider collaborators when developing their implementation strategy.
A defined ROI strategy should connect initial investment to measurable first-year value and longer-term adoption across use cases.
Current state challenges
Administrative waste accounts for an estimated 15–30% of US healthcare spending, with prior authorization alone consuming 14 hours of physician and staff time per week.¹ These inefficiencies will continue to compound as the payer environment grows increasingly complex.
Regulatory demands for transparency and interoperable data exchange are intensifying. At the same time, value-based care contracts now account for approximately 40–45% of US healthcare payments.² Together, these trends are increasing the need for timely, accurate data to measure outcomes, support reimbursement, and improve quality performance, directly impacting CMS Star Ratings and bonus eligibility.³
Risk adjustment adds further pressure, particularly in Medicare Advantage, where incomplete clinical data drives coding variations and an estimated $76 billion in annual payment differences.⁴
At the same time, consumers expect the same seamless, real-time experiences they receive in other sectors. Meeting these expectations is often challenging with inadequate, fragmented healthcare solutions.
Epic Payer Platform (EPP) is designed to help meet this challenge. EPP delivers what fragmented solutions cannot: unified, real-time intelligence that empowers payers and providers to turn complexity into coordinated results. By integrating payers directly with Epic’s electronic health records system (EHR), used by 39% of US acute care hospitals and health systems,⁵ EPP enables secure, real-time data exchange and workflow automation to meet current and future demands. Leading payers already use EPP to streamline data exchange and automate processes such as prior authorization.⁶
Epic payer platform at-a-glance
EPP is a data integration platform that connects directly with Epic’s EHR, enabling real-time clinical data exchange and automated workflows between payers and providers. Its benefits include:
Coordinated care and analytics to help reduce medical cost
Improved data access enables targeted intervention, helping reduce avoidable utilization including readmissions and unnecessary services, and improving medical loss ratio and total cost of care.
Real-time payer-provider data exchange and interoperability
Integration built into Epic workflows eliminates manual chart retrieval, faxes, and portals. Chart chase, information-only adjustment (IOA) costs, and health information exchange spend are significantly reduced.
Proactive care gap identification and closure
Real-time insights enable earlier identification and resolution of care gaps, reducing reliance on manual outreach and improving member engagement and outcomes.
Integrated clinical data that enables risk adjustment, utilization management, and care management
Real-time clinical data streamlines prior authorization, accelerates care decisions, and strengthens coordination, while improving risk adjustment factor (RAF) through stronger hierarchical condition category (HCC) capture and documentation.
Data-driven quality performance and revenue enhancement
Timely, structured clinical data enhances the capture of quality measures and performance reporting. This supports stronger Healthcare Effectiveness Data and Information Set (HEDIS) and Star Ratings outcomes and enables quality bonus payments (QBP) and other quality-based incentives.
Executing with precision
Meaningfully benefitting from EPP requires accounting for the factors that most influence adoption, execution, and ROI. Organizations that do this successfully promote provider participation, build capacity that support meaningful ROI, and strengthen governance.
The successful EPP implementations begin mainly with six critical considerations:
Membership composition and ROI potential
Evaluate whether the membership mix provides sufficient breadth, depth and clinical complexity to meaningfully benefit from an EPP implementation.
Provider buy-in
Determine provider willingness and readiness to participate, establishing shared success criteria, data-sharing expectations, and aligned incentives to accelerate adoption and shorten time-to-value.
Internal commitment and adoption
Align business, clinical, operational, and technology teams around EPP-enabled workflows, ensuring new capabilities are embedded into day-to-day operations and supported by clear ownership and accountability.
Technical and interoperability readiness
Understand how EPP will integrate with core payer systems and assess API readiness, data quality, workflow integration, and overall interoperability to support adoption that grows to meet the organization's needs.
Data usage and performance impact
Evaluate how EPP-enabled data will improve Star Ratings, quality performance, risk adjustment outcomes, and care management effectiveness. This confirms high-value use cases are prioritized from the outset, and accountable owners are assigned by function for value tracking and realization.
Epic ecosystem maximization
Confirm EPP aligns with broader digital, care model, and interoperability initiatives while establishing a long-term roadmap for Epic ecosystem adoption, capability building, and sustained value realization.
Making strategic implementation choices
The next critical step is translating alignment into action. The implementation choices organizations make, like what to activate, where to focus internally, and who to engage, determine the benefits realized and the speed of ROI.
A structured three-part EPP implementation framework provides a clear implementation strategy: One that prioritizes high-impact use cases, while encouraging appropriate adoption to meet current and future needs.
Realizing ROI
EPP does not create value on its own. Organizations need a clear strategy that justifies the investment, implementation timeline, and ongoing costs. Without a defined ROI strategy, adoption alone can not deliver meaningful business impact.
EPP follows a front-loaded investment model, with higher implementation costs up-front and lower maintenance costs over the long term. The figure below is for illustrative purposes only, with investment concentrated in the early phases and value building as use cases are activated, and adoption increases. To accelerate the path to breakeven, organizations should focus on generating measurable value in year one through high-impact opportunities to implement EPP, while continuing to execute against a broader return on investment realization strategy over the course of the implementation. Risk adjustment and quality initiatives are often opportunities for quick wins, with broader administrative and medical cost efficiencies occurring as adoption expands.
The path to ROI will vary based on membership composition. Organizations with a higher concentration of Medicare Advantage and Medicaid members often benefit more quickly because of greater clinical complexity, regulatory requirements, and care coordination opportunities. Commercially weighted portfolios may experience a more gradual path to breakeven. Understanding where membership resides across lines of business is critical to assessing opportunity, determining whether sufficient broad-based demand exists to support the investment, and estimating how quickly you’ll see improvement. This variation is reflected across five key value drivers, where both impact and timing differ by line of business.
Next steps
PwC can help wherever you are in your EPP implementation and use.
If you’re still evaluating EPP, begin by mapping where EPP supports your business objectives. At this stage, organizations often encounter early execution of pitfalls, particularly around unclear prioritization and underestimating the role of provider engagement. PwC can support you in five key areas.
Define strategy and prioritize high-impact use cases.
Establish a clear vision for EPP aligned to business objectives, with early focus on high-ROI use cases such as prior authorization, risk adjustment, and quality performance.
Assess clinical data availability and identify gaps.
Evaluate what data exists today, what is needed to support quality and risk adjustment, and how EPP can help close those gaps.
Build a strong, outcome-driven business case.
Quantify expected benefits across administrative efficiency, quality improvement, and revenue uplift to support investment decisions.
Develop a strategic roadmap.
Prioritize implementation to deliver early wins while building the foundation for broad adoption, reducing risk, and enabling repeated realization of benefits.
Align stakeholders to enable execution.
Drive early coordination across IT, operations, and provider relations to ensure readiness and embed EPP into day-to-day workflows.
If you’ve already implemented EPP, shift the focus to tangible benefits by appropriately enlarging adoption, expanding beyond initial use cases, and generating measurable ROI. PwC can help you by focusing on three key initiatives.
Measure performance and track value realization.
Establish KPIs aligned to the business case, such as administrative savings and provider satisfaction, to monitor progress and course correct.
Scale adoption across the enterprise.
Expand utilization beyond initial deployments by driving provider engagement and extending capabilities across lines of business to generate ROI.
Enhance workflows to embed and sustain impact.
Integrate EPP into core operational processes, leveraging automation and standardized workflows to improve efficiency and sustain long-term utilization.
Contributors: Kayla Johnson, Isabel Sondey, Morgan Naber.
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