Top Three Takeaways from Payer-to-Payer Data Exchange Cohort

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F) is a game-changer in the realm of healthcare data exchange. By championing Fast Healthcare Interoperability Resources (FHIR®), this regulation aims to transform how patients, healthcare providers, and payers access and share health records.

A cornerstone of this Final Rule is the Payer-to-Payer mandate, which requires Medicare Advantage and Medicaid health plans to establish and maintain Payer-to-Payer Application Programming Interfaces (APIs). These APIs are crucial for the seamless exchange of clinical, claims, and authorization data, particularly when members transition between health plans. This presents an invaluable opportunity for health plans to access comprehensive historical information about their new members, facilitating quicker enrollment into appropriate care management and member programs.

Payer-to-Payer Data Exchange Cohort Takeaways

As the mandatory enforcement date of January 1, 2027, approaches, health plans are diligently working to uncover the most effective way to comply with the requirements. What we have found engaging with our health plan customers, however, is a cautionary tale. Many are underestimating the level of effort in establishing point-to-point FHIR connectivity with other health plans.  

As the industry’s premier payer-provider engagement and connectivity platform, Availity profoundly understands the complexity of facilitating data exchange across multiple data standard types and entities. That’s why we created a dynamic partnership with a select cohort of leading health plans to tackle the complex task of facilitating payer-to-payer data exchange. This collaboration aims to pioneer the establishment of an inaugural set of payer connections within our Connectivity Hub, ultimately making it easier to connect to multiple payers through its one-to-many network. 

Availity orchestrated recurring workshops uniting technical teams from each health plan. These gatherings were dedicated to exploring strategies and considerations for executing payer-to-payer data exchange. Throughout these discussions and knowledge-sharing experiences, several key takeaways emerged:

Preparation Sets the Stage for Success

Health plans must prioritize preparation for compliance with the Payer-to-Payer mandate. To date, many health plans have focused on developing their internal FHIR capabilities; operating under the assumption that payer-to-payer exchange will work similarly to Patient Access. However, the real work is in establishing connectivity with other health plans.

Transferring member data to a health plan is a complex technical sequence comprising three critical steps: authentication, member matching, and data retrieval. Additionally, when health plans start to exchange data with each other, shortcomings may emerge due to varying systems, data quality issues, or integration challenges. In the absence of a robust data exchange system, payers might face challenges in responding to information requests or managing data from other payers, which could lead to privacy issues and delays in critical decision-making. 

The network we’re building at Availity is designed to address these challenges while generating multiple economies of scale, a sentiment echoed by one of our inaugural cohort members. By connecting once to our Connectivity Hub, health plans avoid the need for costly and time-consuming point-to-point connections. Our platform handles these connections across the network, reducing the resources needed for integration and maintenance.

Attempting to navigate this process without the guidance of an experienced partner can be daunting. Managing the infrastructure for point-to-point connections, the technical complexities of data transmission, and the need for internal teams to stay current with evolving standards all add to the challenge. With Availity, you gain a partner that simplifies these complexities, enabling your team to focus on what matters most—long-term member health outcomes.  

Early End-to-End Testing is the Cornerstone for Learning

The Da Vinci PDex Implementation Guides serve as use case implementation roadmaps for health plans to navigate the process of facilitating payer-to-payer data exchange. However, health plans who have attempted to establish real-world connections have encountered hidden challenges that the guides do not address. Some of these gaps include: 

• Dead Links: Several references within the guides lead to non-existent pages, causing navigational issues and hindering comprehensive understanding. 

• Use of Authorization Header for Patient Access Token: Normally, the “REST Authorization” header authenticates API Gateway access, verifying user permissions for API interaction. However, the implementation guides now stipulate placing the “Patient Access Token” in this header. Consequently, we asked cohort members who are implementing this standard to devise a workaround for the primary purpose of the authorization header. 

• Credentialing Requirements: Version 1 of the guide mandated that members possess credentials with both their new and old payers. However, the CMS mandate dictates that members only need credentials with their new payer, which then communicates directly with the old payer. 

While discussions and interpretations are valuable, the critical question remains: How can health plans practically test payer-to-payer data exchange?  

Early testing is vital for learning and iterative improvement, as it allows organizations to identify and rectify deficiencies in data exchange processes. As the cohort initiated its preliminary discussions, the primary focus shifted towards realizing the conceptual solution into a tangible reality. Hosting testing workshops has proven highly effective. During the testing workshops, the cohort made significant progress in validating that its service was functioning as expected, as well as uncovering challenges that required continuous refinement to validate the solution amidst the fluctuating ecosystem. 

Taking an end-to-end approach is also important. Testing the viability of a payers internal FHIR API is one thing, but it is imperative to validate that data can be exchanged through the entire payer-to-payer exchange process. The cohort identified early on that organizations who were testing only portions of the overall flow were missing an opportunity to uncover problem areas that would impact future success. By validating from end-to-end at the start, many of these challenges were identified and could be resolved before they had a chance to cause implementation delays.  

Connectivity Requires Collaboration and Engagement

Establishing seamless connectivity between payers demands adherence to specific infrastructure requirements and the implementation of standardized processes. Unlike other initiatives where traditional early adopters could lead the way, payers must take the initiative in this case. Active participation in issue resolution, facilitated by rigorous testing, ensures that health plans can confidently meet compliance requirements and sustain seamless operations. 

As the deadline for mandatory enforcement of payer-to-payer connections approaches, continued collaboration, innovation, and a collective effort from all stakeholders are necessary. Health plans must actively engage with each other to develop effective strategies and share lessons learned. This collaborative approach will pave the way for improved teamwork and innovation in this critical area.  

By reflecting on the lessons learned from the cohort experience and focusing on future directions and opportunities for improvement, the healthcare industry can identify and resolve potential challenges in data exchange ahead of the regulatory deadline and lay the foundation for seamless payer-to-payer data exchange. 

About the Author

As Chief Product Officer of Clinical Solutions at Availity, Ashley oversees corporate and product strategy, leading the product management, clinical informatics, and marketing teams. With over fifteen years of senior product and strategy leadership, she previously directed product and strategy for Optum’s analytic portfolio, managing eight products and launching a flagship offering that integrated clinical and claims data for population health management.

Ashley also served as Vice President of Client Analytic Services, creating an analytics team to support integrated health systems and payers in cost management and value-based care. She holds a Ph.D. in Health Care Management and Policy from Harvard Business School, where she received multiple teaching awards and published over a dozen articles, including a widely used case study on collaborative accountable care.