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Providers, payers struggle with CMS interoperability rule

Discover key challenges healthcare stakeholders face in complying with the CMS interoperability and prior authorization final rule.

Hannah Nelson
By
Published: 10 Apr 2025

Healthcare stakeholders are facing significant challenges in meeting the requirements of the CMS Advancing Interoperability and Improving Prior Authorization Final Rule, also known as CMS-0057-F, according to new survey results from the Workgroup for Electronic Data Interchange (WEDI).

The final rule outlines requirements to increase data sharing for patient access, provider access, payer-to-payer and prior authorization APIs. These new provisions aim to reduce payer, provider and patient burden by streamlining prior authorization and data exchange. Impacted entities must implement the API requirements by January 1, 2027. The rule also requires covered payers to publicly report designated prior authorization metrics by Jan. 1, 2026.

The survey was open to the industry from January to February 2025. Survey responses totaling 243 represented 45% payers, 25% vendors, 21% providers and 9% clearinghouses.

Provider responses

Over half of providers (52%) reported they had not yet started work on the API requirements. The top implementation issues reported were sufficient funding, determining a cohesive interoperability strategy, and understanding various health information exchange networks and how they interplay.

The survey found that most providers (44%) are uncertain of the total cost for implementing the final rule requirements and training their employees.

Further, 79% of providers said that having most of their payers supporting the prior authorization requirements was very important or extremely important.

Payer responses

Across payer respondents, 43% have not yet started work on the API requirements and 31% are one quarter completed. The top challenges reported were determining an enterprise interoperability strategy, digitizing prior authorization policies and obtaining sufficient funding. The majority (35%) estimate a cost of $1 million to $5 million for implementing the API components of the rule.

Clearinghouse responses

A significant majority of clearinghouse respondents (84%) plan to assist payers and providers with the rule's API requirements. For the prior authorization API, 81% plan to implement both the FHIR and X12 solutions.

Vendor responses

Most vendors (81%) plan to assist payers and providers in complying with the requirements of the final rule. However, while 36% of vendors plan to support consumers with the patient access API, 32% do not.

Additional survey results

Across stakeholders, the top three cited educational resources to support CMS-0057-F implementation were education on industry best practices, education on workflow design/modification and technical education on implementing APIs.

“The survey results suggest that a substantial percentage of both payers and providers have not yet started to implement these API mandates, or have only partially completed their implementation efforts,” Robert Tennant, WEDI executive director, said in a press release.

“These API requirements are very complex and for many stakeholders, they represent a completely new approach to data exchange,” Tennant added. “It is not surprising that identifying funding, modifying business workflows and determining a cohesive enterprise strategy for interoperability were cited by many as critical challenges.”

WEDI plans to repeat the survey on a regular cadence until the January 2027 compliance date to track the healthcare industry’s progress in meeting these requirements.

“In sharing the data with the industry and developing best practices and guidance, we hope to facilitate adoption of this new and potentially game changing technology,” Tennant emphasized.

Hannah Nelson has been covering news related to health information technology and health data interoperability since 2020.

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