Why Payers Must Go Beyond Compliance with the Interoperability Rule

The Interoperability and Patient Access Final Rule presents a near-term challenge for payers in terms of compliance with its provision for data access and sharing. It provides an opportunity for health plans to consider more carefully the long-term benefits of making high-quality data available for improved decision-making and health outcomes on the clinical side and better risk assessment and adjustment on the operational side of the house.

Within the final rule, the Centers for Medicare & Medicaid Services (CMS) requires payers to share healthcare and claims data with patients, providers, and other payers using secure health IT standards known as Fast Healthcare Interoperability Resources (FHIR) and not participate in information blocking to avoid strict financial penalties.

Although the federal agency extended the compliance deadline from January 1 to July 1 of this year, its timeline still proved challenging to many payers unfamiliar with FHIR adoption and implementation. Compounding the challenges, payers managed these challenges with limited technical infrastructure and operational setup.

In a survey of 111 payer professionals prior to the July 1 deadline, well more than half (63%) were somewhat prepared or in need of time and assistance to achieve compliance on schedule. Clearly, many payers felt hard-pressed to complete all the preparation required by the new regulation.

“They have to learn the FHIR 4.0 standard, they have to find the data, gather the data and orchestrate the data,” says Jay Sultan, Vice President of Health Care Strategy at LexisNexis Risk Solutions. “They have to increase the speed at which the data moves and make all of that data available externally. This includes data on claims that the payers don’t adjudicate themselves — claims that they pay someone else to process on their behalf. Every bit of this is new to them and it’s a major lift.”

The final rule has also created unease among payers, many of which (37.8%) expressed concerns about patient privacy and adhering to security standards under HIPAA as a result of having to share protected health information (PHI) externally — especially with third-party applications used by patients and other payers via application programming interfaces (APIs).

While sharing data with other stakeholders is an important component to complying with the CMS final rule, it is secondary to the task of first having complete, high-quality data available within the organization. Respondents listed the availability of clean-high-quality data as the most helpful capability to comply with the CMS data sharing mandate (39.6%), followed by the ability to ingest and normalize data from a wide array of sources (33.3%).

In truth, the rule represents a watershed moment for payers to put in place health data infrastructure capable of supporting the future of healthcare, using the data to benefit their members and their business. Therefore, payers must approach the rule as a baseline, with those organizations willing to go beyond compliance most likely to stand out in a highly competitive marketplace.

Payer attitudes reflect this reality. Although the costs associated with data extraction standing up FHIR-compliant servers and other infrastructure remain a roadblock for a majority of payers, they are making necessary investments in light of the high value payers place on clean, high-quality data (39.6%) and their ability to aggregate and normalize information from a growing number of data sources (33.3%).

To set themselves up for long-term success, payers are increasingly realizing the need to identify technology partners and solutions integral to data aggregation, normalization, and sharing. By and large, they are implementing new data governance procedures and exploring how third-party partners can augment their internal resources to achieve compliance.

“To meet the rule’s requirements, payers have to cultivate new capabilities,” Sultan explains. “There’s simply a lack of capacity and a lack of knowledge to do this internally, so payers are looking to either buy new software, procure new services to create the necessary software or pay a vendor to take care of it all as a service.”

While cost is a key factor in this process, payers are much more concerned with a third-party organization’s expertise working with their current technology systems — 54 percent to 40.5 percent.

With the clock ticking for payers to comply with the CMS interoperability mandate, these organizations cannot afford to miss out on the opportunity to transform their infrastructure and operations by making high-quality data a staple of their business. For data to support timely and effective care delivery additional business value, it must be complete and actionable, which depends greatly on an organization’s ability to ingest, cleanse and standardize pertinent patient data from across the healthcare ecosystem.

In essence, the Interoperability and Patient Access Final Rule has created a new playing field where payers use and share data rather than only having access to their own silos. Efforts to supplement data and improve its liquidity, often requiring payers to seek out technology partners and solutions, will ultimately determine a payer’s status as an industry leader and innovator.

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The Health Care business of LexisNexis Risk Solutions combines proprietary analytics, data science and technology with the industry’s leading sources of provider, member, claims and public records information to deliver insights that improve cost savings, health outcomes, data quality and compliance.