Two Paths to Health Data: HIPAA Versus Patient Portal

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Felicia McElhaney
Senior Director, Life Underwriting Innovation, LexisNexis Risk Solutions

April 2026

“Is this applicant’s condition stable?”
“Where are the vitals I need to apply my underwriting guidelines?”
“I was looking for recent cardiac data, but it’s not here. Does it not exist, or do I need to order more evidence to get it?”

Many carriers think about underwriting data in terms of hit rates: You can get a record, or you can’t. But underwriting data can’t just exist — it must also answer the question being asked.

Most carriers think they’re optimizing for hit rate, but what ultimately matters is decision rate. Decision rate reflects whether the available data are sufficient for an underwriter to decide without ordering more evidence.

To see why the distinction matters, consider how two paths to digital health records — one based on consumer-mediated consent (CMC) via the patient portal and one authorized under the Health Insurance Portability and Accountability Act (HIPAA) — perform in practice.

Recency Matters

“Given what the applicant has disclosed, how stable is their medical condition? Is this person a candidate for accelerated underwriting?”

Recency has always mattered in underwriting, but it’s critical for accelerated programs. Our analysis shows consumer-mediated pathways are nearly twice as likely as HIPAA-authorized approaches to return vitals and labs from the past 12 to 18 months, according to internal data from LexisNexis.

For example, consider an applicant who discloses hypertension.

Carrier A only uses HIPAA-authorized paths and retrieves labs and vitals that are more than three years old. Without recent data, the applicant is pulled into manual underwriting, triggering additional evidence and longer cycle times — even though the underlying risk hasn’t changed.

Carrier B has access to both consumer-mediated and HIPAA-authorized paths and starts with consumer-mediated access to digital health data from the applicant’s primary care provider. Recent labs and vitals confirm stable hypertension, so the case remains in accelerated underwriting with no additional evidence required.

Reliability

“Do I have the details I expect to see for this risk profile?”

HIPAA-authorized paths are designed to maximize coverage. That means you get a lot back, but you don’t always get what you were looking for. In contrast, consumer-mediated paths create more precise connections to relevant providers — and as a result, more consistently return the expected data. Our research shows improvements of at least 10 percentage points across major underwriting elements and more than 20 percentage points in common labs and key impairments.

Consider an applicant with Type 2 diabetes in manual underwriting.

Using HIPAA pathways only, Carrier A obtains records from urgent care facilities and e-visits. The diabetes diagnosis is visible, but A1C levels are outdated, labs are sporadic, and visits appear to have been infrequent. Unable to apply underwriting guidelines, the underwriter orders an attending physician’s statement (APS) — which increases costs and cycle time.

Starting with consumer-mediated consent, Carrier B is connected with the applicant’s primary care provider and endocrinologist. Records show stable A1C readings, regular visits and overall good compliance. The underwriter can confidently apply underwriting guidelines to move the file ahead.

Sufficiency

“Do I have the right data to decide?”

Recency and reliability are what make data sufficient — and that shows up in decision rates. Our analysis shows decision rates of over 70% with consumer-mediated pathways, roughly 25 percentage points higher than with HIPAA-authorized approaches.

For example, consider an applicant with a history of chest pain.

Using HIPAA-authorization pathways only, Carrier A obtains primary care records showing a note about chest pain and a referral to a cardiologist — but no recent cardiac testing. With no way to tell whether that data is missing or doesn’t exist, the underwriter orders APS records from both physicians. While the APS adds detail, it also adds review burden — and still doesn’t guarantee clear answers. After several weeks, the underwriter reaches the end of the available evidence and makes a decision.

Starting with consumer-mediated pathways, Carrier B accesses digital health data directly from the applicant’s primary care physician and cardiologist. In the cardiologist’s file, notes show the diagnosis of noncardiac chest pain, that no imaging is required, and that the applicant has routine, ongoing follow-up appointments. These data are sufficient for decision making with no further evidence required.

Moving Decisions Forward

In these examples, consumer-mediated pathways provide precise, early answers to underwriting questions. When questions persist or a broader view is needed, HIPAA-authorized searches can help confirm whether missing data reflects good health or if care is happening elsewhere.

Used together, consumer-mediated and HIPAA-authorized approaches shift the focus from retrieving records to resolving underwriting questions — driving higher decision rates and fewer unnecessary escalations.

LexisNexis Health Intelligence

LexisNexis Health Intelligence has enabled leading carriers to make decisions with an EHR more than 70% of the time without requiring additional evidence. Health Intelligence gives you access to both consumer-mediated and HIPAA-authorized data, with orchestration that allows you to automatically pivot between data sources — and, if needed, also order an APS. Learn more.

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