Well before Accolade bought them, 2nd.MD was getting frequent health insurer file feeds of employee / member / patients who were facing complex clinical events—such as a pending spinal surgery—to facilitate outreach for second opinions.

The time sensitivity of the outreach was critical: if they didn't connect with the member PDQ, the chances of "eventually" completing a second opinion review dropped dramatically. These days, while file feeds haven't completely disappeared, there's a clear movement towards real-time APIs, particularly on the health care side.

Real-time API orchestration
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) mandated that impacted payers (MA organizations, Medicaid, CHIP) implement HL7 FHIR-based APIs for prior authorization by January 1, 2027. Payers must now respond to "urgent" PA requests within 72 hours and standard requests within 7 days.

And as I wrote about the summer before last, this concept of Pre-Cert as a sentinel event is beginning to show up more broadly. Somewhat surprisingly - to me at least - it's often being described as "point-of-care" interventions, and some of the heaviest usage is being facilitated by pharmaceutical companies seeking to get "their drugs" prescribed to members, striking while the iron's hot, so to speak. Which seems likely to yield cost increases rather than cost savings!

Point solution and health management vendors should take note
With employer health plans facing rising costs driven by diabetes, musculoskeletal (MSK) procedures, oncology, and specialty drugs, the focus for consultants and employers alike is shifting towards the specific timing of the outreach efforts and interventions.

Think about it - there is no better time to catch an employee / member / patient at the precise moment of "high interest" than when a significant care event is imminent! The individual needs something, and the doctors and facilities want to get paid. And the degree of "precision engagement" that can be brought to bear is also high: at this millisecond, a procedure code (CPT) is linked to a diagnostic code (ICD), but care has not yet been delivered.

"We're here to help"
Connecting with the employee / member / patient at the point of care or point of interest feeds directly into quantifiable, improved clinical outcomes and, often enough, measurable health plan cost savings. When an employee considers a procedure, such as a knee replacement, waiting seven days for a claim file is suboptimal. A real-time trigger enables a clinical engine to act while the situation is still "ripe."

This real-time capability allows for:

• Orchestrated Immediate Intervention: Providing a second opinion consult before a surgery is even scheduled.

• Redirection of the Site of Care: Steering the member from a high-cost hospital outpatient department to a lower-cost Ambulatory Surgical Center (ASC) the moment the diagnostic signal is detected.

• Strategic Program Enrollment: Intercepting a pended specialty drug PA to immediately solicit a member into a high-risk clinical management program, rather than waiting for a coverage denial to trigger a manual inquiry.

Leveraging technical standards across the market
While current regulatory directives are more focused on government-aligned plans, the implications for the employer market are clear.

Market trends suggest that self-insured employer clients will soon demand the same level of clinical orchestration. If carriers are building the API infrastructure to provide Medicare members with automated real-time PA checks, there is little reason for self-insured plans to remain tethered to cumbersome file feeds.

Forward-thinking vendors are already preparing for this shift toward FHIR APIs. Major navigation platforms and point solutions, including Accolade, Transcarent, and specialized entities like Sword Health, are transitioning toward AI-driven orchestration that ingests real-time signals. This represents a move beyond "predictive analytics" based on historical data toward "active orchestration" powered by real-time API triggers.

The path forward in health management
Within the next 24 months, clinical advocacy will likely be defined by a vendor's ability to serve as a real-time middleware layer between health plan data and the employee’s point of care.

Prioritizing the adoption of the HL7 Da Vinci Project Prior Authorization Support (PAS) implementation guide is now a strategic necessity. Developing the capability to monitor PA APIs and trigger outreach while a member's clinical situation is unfolding is essential for reducing avoidable care and controlling employer healthcare spend.

The last word
There is no better time to connect with an employee about helping them navigate not only their immediate health situation, but also the complexities of the system itself. Now, consider further tailoring your outreach by aligning with the member's psychographic profile. If ever there was a time when someone would be willing to answer a short quiz that reveals their world views, beliefs, values and priorities, it's when they need care - and when help is right there on tap.

~ Mark Head

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