Improving Benefits Certification Through Thoughtful Healthcare Sector Partnerships and Digital Tools

Paid family and medical leave (PFML)  is a critical support for families when injury or illness sideline individuals from their jobs. But in the 13 states that require medical certification for state PFML benefits eligibility, receiving paid leave is often delayed by a verification process that requires coordination between the claimant, the state, and their healthcare provider—which puts the onus on the claimant to deliver complicated paperwork to the state.

It’s an onerous process for everyone involved. The claimant’s medical provider must accurately record their patient’s health records into whatever form is required by the state and provide it to the claimant, who then must transmit that form (whether physically, via fax, or uploaded into a claimant portal) to the state. One small mistake in the paperwork or the transmission process can take weeks to rectify, and can create significant delays for families in desperate need of financial support. Certification paperwork mistakes are a major source of delay in PFML adjudication.

However, there is promise for another approach: many public benefits programs have sought to bridge the software systems that healthcare providers use and the claim management software systems that benefits programs use, enabling medical providers to send information directly from their software systems to the state’s software systems.

The idea is gaining steam in the US, including among at least four states with state Paid Family and Medical Leave (PFML) programs. The New Practice Lab has helped several of those programs, including Minnesota, Colorado, and Washington, explore the concept, iterate, and learn from each other’s experiences. 

Here’s what we’ve found out along the way:

Health Sector Software Tools Can Help Make Benefits Certification Easier

• Healthcare Providers Do Everything Inside EHRs

  Healthcare providers rely on electronic health records systems (EHRs) like Epic and Oracle Health in their work. A healthcare system’s chosen EHR is where providers reference details from previous patient visits, send out test orders, summarize patient conversations, and complete many other core workplace tasks. All major EHRs support transmitting patient information to outside entities (like pharmacies and health tracking apps) as a normal function of the software. Transmission typically occurs using healthcare data standards like FHIR (Fast Health Interoperability Resources), which are widely supported across the health sector and help ensure data security and privacy.

  As a result, EHRs are key to unlocking digital certification. In a 2025 sprint we ran with Minnesota, the New Practice Lab tested and verified that the state PFML program could feasibly use FHIR data fields to receive medical certification paperwork. This would allow healthcare providers to transmit claim certification information directly from their EHR to a benefits program, minimizing the paperwork burden for medical providers and claimants while greatly reducing the possibility of errors in certification paperwork and cutting down on processing time once the program receives a claim certification.

  An EHR-based digital certification pathway can also aid program integrity by guaranteeing that the source of incoming certification information is trustworthy: communications sent via medical data standards like FHIR can be verifiably attributed to the healthcare system and healthcare provider that sent them, thus reducing the chance of fraud. Successful implementation of an EHR-based digital certification system, therefore, can improve the quality of program experience for non-state stakeholders and make the state’s job easier at the same time.

Collaboration Is Essential to Making Digital Certification Work

• Partnering with Healthcare Systems
  Despite advantages over traditional benefits certification methods, EHR-based digital certification is not yet widespread in US public benefits programs. EHRs are complicated software tools, and domain knowledge about how they function is more commonly found in healthcare fields than in benefits programs. Benefits programs will likely need to partner with healthcare systems to scope, prototype, and test certification solutions that work for all parties.

  Partnership allows the program to learn from health sector EHR expertise and ensure that proposed solutions are feasible for providers across different healthcare systems and different EHRs.

  EHRs are not one-size-fits-all across healthcare systems. There are multiple EHR vendors, and configuration of a given EHR can vary significantly from one medical practice to another. A PFML program that’s interested in digitally certifying claims should seek engagement with multiple healthcare systems to ensure that a planned EHR-based certification solution is usable by different healthcare systems with different technical setups.

• Finding the Right Healthcare Staff for Collaboration
  Just like the EHRs they use, healthcare systems themselves are often complex and challenging to understand from outside. When seeking health sector collaborators, a public benefits program should seek to engage stakeholders who have a bird’s-eye view of their healthcare system’s EHR, and who can gather other relevant staff in their organization to contribute to the effort.

  Generally, that means the program should try to connect with people like Chief Medical Informatics Officers (CMIOs), who are commonly found in large healthcare systems and whose responsibilities include oversight of the healthcare system’s chosen EHR. CMIOs are often also practicing healthcare providers, familiar with their healthcare system’s EHR as both an IT planner and an end user.

  That said, the person whose job title best matches external expectations for a well-positioned collaborator may not always be ready to get excited about the idea and direct resources to the work. Sometimes the best collaborator is simply someone within a healthcare system who is reachable and already familiar with the government program.

  While large healthcare systems can often explore the full realm of possibility more capably than their smaller peers, it is important to retain engagement with leaders at smaller healthcare systems who don’t benefit from a high level of in-house technical expertise (including those who don’t have a CMIO) to avoid overfitting a solution to large healthcare systems. Small healthcare systems may not have much (if any) dedicated technical staff, and may need help from their EHR vendor to implement new processes. This limitation has implications for which possible digital certification tools are possible for those smaller systems to implement.

• Balancing Your Program’s Needs with the Needs of Healthcare Systems
  There are many technically feasible ways to securely fill and transmit certification information to a public program using features of a healthcare system’s EHR.  Benefits programs must become familiar with EHR technologies (like FHIR APIs, medical data security protocols, and vendor-specific EHR features) in order to knowledgeably determine how to build an EHR-embedded digital medical certification tool that balances the needs of diverse healthcare systems and the program.

  Different healthcare systems may have different preferences for which EHR features should be used to fill and transmit certification paperwork. An EHR feature that one healthcare system may desire to use for digital certification may be unavailable to others, either due to feature paywalls or because those features are specific to one EHR vendor. Finding an implementation path that uses widely supported data standards like FHIR, and therefore is extensible beyond the context of just a few healthcare systems,  is key to rolling out digital certification successfully.

  Sometimes, a benefits program may choose to pursue a semi-custom pilot solution for digital medical certification to keep a partner healthcare system engaged in the short term, even if that pilot solution is not particularly generalizable outside the partner’s technical environment. This can serve as a stepping stone to a more generalizable long-term solution (either by building portions of the more generalizable solution within the semi-custom pilot solution, or by simply keeping a pilot partner engaged), while immediately improving the certification experience for claimants who receive services from that healthcare system. If a benefits program chooses to work on a pilot solution that’s particularly suited to the needs of one or two partnered healthcare systems early on, the program should maintain a path towards an eventual solution that a wider range of healthcare systems can make use of.

Thoughtful Partnerships Produce Better Digital Government Services

During scoping, software development, and even after launch, a program’s digital certification project plans will likely shift. Regular, ongoing engagement with a wide range of healthcare systems will help evolve the state’s chosen digital certification tools so that they remain helpful, rather than rigid or burdensome, for healthcare providers, claimants, and the program.

EHR-based digital certification is a promising prospect for PFML programs in the US, with the potential to improve benefits certification processes while simultaneously reducing fraud risk. State PFML programs in Massachusetts and Minnesota have already rolled out EHR-based digital benefits certification solutions, and several additional states are working on the same challenge, but these solutions are not yet widespread and there is no single widely agreed-upon technical approach to EHR-based  digital certification.

These tools must be thoughtfully implemented in order to meet their potential, with possible applicability across other benefits programs that require third-party medical certification, including programs like workers’ compensation. Engaging with healthcare providers and the healthcare systems they work within can help ensure that a public benefits program’s desire to improve medical certification through digital tools results in something truly helpful for healthcare systems and the people they serve.