Payers Face FHIR, API Adoption and Next Steps for Interoperability


Research reports that by 2030 there may be an entirely new healthcare ecosystem. To succeed, the health insurance companies of today are advised to become highly patient-centric and continue to invest in technology and innovation. The push toward full transparency for preauthorization and costs of medical procedures can only happen with the expanded use of electronic tools and advanced applications. This push, along with new regulations on the horizon, may require payers to rethink their technical strategy and the solutions they need now and in the future.

Payers Face FHIR, API Adoption and Next Steps for Interoperability

The 900 U.S. health insurance companies known as “payers” are a key link in keeping the wheels of healthcare turning. Payers are tasked with providing efficient preauthorization and cost transparency information for patients, among other things outlined in the 21st Century Cures Act.

Acceptable information flow between payers and providers is overdue as some organizations continue to use fax or even snail mail for medical information between stakeholders which adds $25 billion a year to the bottom line.

A lack of transparent cost information also continues to plague the industry with only 24.5 percent of 2,000 hospitals surveyed ranked as compliant with posting procedure prices online in an easy to access, searchable format. With costs high and sometimes unclear, 40% of consumers declined care in the past year. Others opted out of needed care because they feared a surprise bill. When consumers forgo procedures to save money or because they don’t trust the system, preventative care suffers which then affects long-term health outcomes.

Payers’ use of technology solutions for data management, medical billing and claims processing are continually stretched to meet evolving needs.

Payers have broad responsibilities to acquire and deliver all the benefits and coverage they represent. Having efficient and accurate exchange of electronic preauthorization and cost information is a top priority that may require technology, application, and infrastructure investments. As payers continue to adapt to regulatory requirements, they also need to keep an eye on what is next and ensure they have the technology tools needed to get the job done.

New rule on deck aims to use FHIR and API to better connect patients, payers, and providers.

There are new rules on the horizon that will leverage available Fast Healthcare Interoperability Resources (FHIR) standards for better online data sharing between patients, providers, and payers.

The CMS rule (0057-P) for Advancing Interoperability and Improving Prior Authorization Processes is expected to be in effect by Jan. 1, 2026, and has a goal of ensuring that health information is readily available at the point of care by leveraging FHIR standards. It focuses on using application programming interfaces (API) to enable different electronic applications to communicate with each other. This data sharing advancement will add guidance for several areas in the payer’s realm, including:

  • Patient Access API
  • Provider Access API
  • Payer-to-Payer Data Exchange API
  • Prior Authorization Requirements, Documentation & Decision API
  • Improving Prior Authorization Processes
  • New measures for Electronic Prior Authorization for the Merit-based Incentive Payment System (MIPS) Promoting Interoperability Performance Category and the Medicare Promoting Interoperability Program

The rule also includes several proposals intended to reduce payer, provider, and patient burden by streamlining prior authorization processes to move the industry toward a fully electronic prior authorization process.

To be ready for future rules, payers have many items on their to-do lists.

A few things under current consideration for future rules include:

  • One-day patient communication. Communicating with patients within one business day via the Patient Access API about prior authorization requests and decisions.
  • Annual use reporting. Preparing annual reports for CMS with de-identified data to show how patients are using the Patient Access API.
  • Better connecting payers and providers. Building and maintaining a FHIR API for sharing claims and encounter data to facilitate the exchange of patient data between payers and providers.
  • Enhanced data exchange between payers. Being ready to supply new payers with patient data within one week and supporting patients with concurrent coverage with quarterly updates.

Payers focused on the future need to be sure of their data integration capabilities to help support a seamless flow of information to benefit patients, providers, and their own organizations. CMS has proposed specific technical standards with which each API would need to comply.

Future rules may also include improving the data sharing of social risk and behavioral health information using APIs.

Payers may feel the stress of rapid implementation of FHIR servers.

With all the new and anticipated future requirements for payers, there may be some shifting and new solutions needed. Some payers, forced to comply with federal requirements of FHIR server implementation, had little time to strategize about data feeds and server utilization which can create other challenges. To address this, there needs to be a thoughtful forward-looking technical strategy.

Payers can adapt for the future with an updated technical strategy.

The new and anticipated future rules for the speed and access for data sharing between patients, providers and other payers might require an updated technical strategy.

Research shows that by 2030 the health industry will move into a new health ecosystem. The report suggests that to succeed, health service companies (the providers and payers of today) should be highly patient-centric and continue to invest in technology and innovation.

Our team is agile, experienced, and ready to help ensure health, billing, employee, and other records managed by HMOs, group health plans, Medicare and Medicaid are secure and interoperable.

Our HealthData PlatformTM is a scalable solution that offers storage, workflows, transactions, and the interoperability needed today, and tomorrow.

Our team has in-depth experience in every step of lifecycle data management for clinical, financial and operational records, including: rationalization, extraction, migration, conversion, retention, integration and destruction.

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Nov 03 2023

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