6 Hidden Challenges of Payer-to-Payer Data Exchange

The Centers for Medicare & Medicaid Services (CMS) Payer-to-Payer Data Exchange mandate might seem straightforward on paper, but in reality, implementing it is far more complex than many health plans realize. Waiting until the 2025–2026 window to begin could leave your organization scrambling to meet the 2027 enforcement deadline, potentially exposing you to costly penalties and operational disruptions.

Starting early allows you to proactively address unexpected challenges in meeting compliance. But it’s not just about ticking the compliance box—it’s an opportunity to establish a robust system for sharing member data. This foundation is key to creating comprehensive health records, closing care gaps, and ultimately driving improved health outcomes.

Here are six often-overlooked challenges that health plans face on their journey to implementation—and how proactive planning can help you overcome them.

1. Resource Dependencies and Development Delays

Establishing payer-to-payer data connections is a resource-intensive process. Many health plans underestimate the amount of time, staff, and expertise required. One large payer reported needing six to eight people working for six months to establish a single payer connection. When scaled across multiple connections, the resource burden becomes overwhelming, especially when competing with other internal priorities like utilization management and risk adjustment.

Solution: Start early to allocate the necessary resources, ensuring that you don’t encounter bottlenecks at critical stages of implementation.

2. Evolving Standards Add Complexity

The standards underpinning the Payer-to-Payer Application Programing Interface (API) CMS mandate, such as the Payer-to-Payer Bulk API, are still evolving. While foundational frameworks like Fast Healthcare Interoperability Resources (FHIR®) provide a strong starting point, frequent updates and nuanced interpretations of Health Level Seven (HL7®) International implementation guides can create unforeseen connectivity challenges.

Solution: Monitor changes in standards closely and collaborate with industry peers to identify gaps and standardize your approach.

3. Knowledge Specialists are in High Demand

Successfully implementing payer-to-payer connections requires specialized expertise in FHIR and interoperability. However, finding and retaining skilled staff with experience in this niche area is becoming increasingly difficult as demand rises across the healthcare sector.

Solution: Partner with vendors or external teams that have deep expertise in FHIR to reduce the learning curve and avoid future resource constraints.

4. End-to-End Testing is Critical Yet Overlooked

End-to-end testing often gets deprioritized, but it’s vital for ensuring compliance. Testing allows your team to resolve authentication issues, validate APIs, and standardize service functionality before going live. By testing early and often, your team can uncover hidden challenges, refine processes, and build confidence in the system’s performance under real-world conditions. Skipping this step can lead to costly delays, failed connections, and unnecessary troubleshooting during critical stages of implementation.

Solution: Build a robust testing framework early in the process to identify and resolve issues in a controlled environment.

5. Maintaining Connections is a Long-Term Commitment

Once you’ve established connections, the work doesn’t stop. Maintaining and enhancing them requires ongoing monitoring, updates, and troubleshooting. Without proper planning, your team could struggle to keep pace with new requirements and operational demands.

Solution: Develop a maintenance strategy that ensures your connections remain functional, compliant, and scalable as standards and requirements evolve.

6. Small Variances Create Big Connectivity Challenges

Even when using standardized frameworks like HL7, minor differences in how payers implement their connections can create significant roadblocks. Issues like slight variations in authentication protocols or data mapping can slow down integration efforts.

Solution: Collaborate with a network of payers early to identify and address these variances, ensuring smoother connections and greater interoperability.

Why Starting Early Is Key

Waiting to begin the compliance process until closer to the 2027 enforcement deadline increases your risk of:

• Operational delays that disrupt your connectivity with other payers.
• Higher resource costs as demand for skilled staff and vendor support intensifies.
• Penalties and compliance risks due to incomplete or incorrect implementation.

By starting now, your organization can lead the way in shaping the future of payer-to-payer data exchange. Early action allows you to establish seamless connections, collaborate with industry peers, and avoid unnecessary delays.

How Availity Can Help

At Availity, we’re making payer-to-payer data exchange more efficient through our Availity Connectivity Hub. Our one-to-many connection point eliminates the need for payers to build and maintain countless individual integrations, providing a fully validated and scalable network of connections.

By joining our network, you’ll not only save time and resources but also gain peace of mind knowing you’re on the right path to meet the Payer-to-Payer API component of the CMS Interoperability and Prior Authorization Final Rule. We handle the heavy lifting so you can focus on what matters most—closing care gaps and improving health outcomes.

Don’t wait until it’s too late. Check out our infographic to discover how starting early can help you avoid penalties and delays. Learn about the biggest challenges ahead and get actionable steps to stay on track for success.

View the Infographic Now