Turning Interoperability into a Competitive Advantage

The deadline to achieve compliance with the provisions of CMS-0057-F is rapidly approaching. Payer organizations have less than a year to implement FHIR® APIs for sharing prior authorization information, payer-to-payer data, provider access, and patient access. With so little time left to meet the requirements of CMS-0057-F, many organizations may be tempted to take the path of least resistance: selecting solutions that support compliance at the lowest cost and with the shortest implementation timeframes possible.

While this approach may reduce expenses and minimize disruption in the short term, compliance-only solutions are just stopgaps. Eventually, they may create additional challenges for your organization, such as increased data fragmentation, needing manual workarounds to compensate for their limited functionality, and requiring constant updates and modifications to keep up with evolving regulations.

As we’ve said before, a compliance-only approach to interoperability makes it harder for your organization to thrive in an increasingly competitive healthcare landscape. Broadening your interoperability strategy beyond compliance allows you to unlock capabilities that deliver significant value across your enterprise—and enhance provider, partner, and member experiences to boot. Here’s how.

Accelerate Care Decisions

As the name “CMS Interoperability and Prior Authorization Final Rule” suggests, improving the prior authorization process is a major part of CMS-0057-F. Key stipulations of the rule include automating the exchange of prior authorization data, ensuring that data is easily accessible to providers and patients, and establishing timeframes for payers to process prior authorization decisions.

The rule is an important step in reducing administrative waste and delays related to prior authorization, which is a costly problem in healthcare: according to the Council for Affordable Quality Healthcare (CAQH), the industry spent $1.3 billion on administrative costs related to prior authorizations in 2023.

The full cost of inefficient prior authorization processes is harder to calculate, but it is no doubt significant. Delayed prior authorization decisions can prevent providers from making fast care decisions or members from accessing the treatment they need. In a 2024 AMA survey, 93% of physicians reported care delays associated with prior authorization, and 82% said prior authorization can sometimes, often, or always lead to treatment abandonment. This, in turn, can contribute to poor health outcomes and higher care costs in the long run for members, providers, and even payers.

Investing in interoperability to streamline data exchange supports faster prior authorization decisions, particularly when coupled with the prior authorization APIs (PAAPIs) stipulated by CMS-0057-F. Faster decision-making means more opportunities to improve care outcomes, which leads to better member health—and lower long-term costs.

Better Analytics, Better Collaboration

Relationships between payers and providers have become increasingly adversarial, particularly as the industry has shifted to value-based care. Too often, payers and providers are attempting to achieve the same outcome—improve patient/member health at lower cost—with disparate information and misaligned parameters for success.

The consequences of this discrepancy are significant: increases in denials and claim rejections, incomplete reimbursements for care delivery, and ultimately erosion in the payer-provider relationship. At its core, the problem stems from poor communication and collaboration: 61.5% of survey respondents said their biggest challenge is keeping track of payer-specific rules and documentation requirements.

In today’s data-driven value-based care (VBC) environment, enhanced data quality is invaluable to providers. Improving data quality and data exchange allows you to share valuable and actionable insights that providers can use to deliver better-quality care for members. By investing in interoperability, your organization can build a cleaner data foundation and more readily share that information with your provider partners. Not only does this lead to better care quality—which supports better member health outcomes and lower costs—but it can be a key competitive differentiator.

Providers are unfortunately accustomed to receiving poor-quality data, delayed data, or sometimes no data at all from their payer partners; by seamlessly delivering data that providers can use to inform their care delivery, your organization can build a reputation as a true partner. That reputation will be crucial when the time comes for providers to decide which payers they want to contract with.

Regulatory requirements are perpetually evolving, and a compliance-first approach will always leave your organization scrambling to fulfill the technical requirements of future mandates. A strategic approach enables your organization to stop chasing compliance and instead focus on building a sustainable foundation for long-term interoperability and achieving competitive differentiation.

To learn how Edifecs can support your organization’s journey toward achieving strategic, compliant, and future-proof interoperability, get in touch with our team today.