Uncovering Payer-to-Payer Mandate Challenges

The Payer-to-Payer Data Exchange mandate, a requirement of the Centers for Medicare & Medicaid Services Interoperability and Prior Authorization Final Rule, requires impacted payers to implement and maintain Payer-to-Payer Application Programming Interfaces (APIs) to exchange clinical, claims, and authorization data when a member moves between health plans. These APIs will facilitate the exchange of member data with other payers. Want to learn more about payer-to-payer data exchange requirements? Click here for a detailed breakdown.

With the fast-approaching mandatory enforcement date of January 1, 2027, many health plans are deep in the process of uncovering the most effective way to comply with the requirements. At Availity, we understand the complexity of facilitating data exchange across multiple data standard types and systems. That’s why we have embarked on 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 the inaugural set of payer connections within Availity’s Connectivity Hub, ultimately making it easier to connect to multiple payers through its one-to-many network.

The cohort was initiated on August 22, 2023, with the primary objective of collaboratively identifying and addressing pivotal decision points related to payer-to-payer connections. Using the Da Vinci PDex Implementation Guides as a roadmap, the cohort aims to uncover hidden challenges associated with payer-to-payer connections and determine the most effective and repeatable process for establishing connections with other payers.

The objectives for the inaugural cohort included:

• Facilitate the exchange of clinical, claims, and authorization data upon member request.
• Identify best practices for payer-to-payer data sharing through Availity’s Connectivity Hub.
• Prioritize the expansion of payer connections to enhance the Connectivity Hub.

Challenges Uncovered

As the cohort collaborated and exchanged insights, several noteworthy challenges surfaced due to a combination of internal and external factors.

Firstly, the scale of the challenge payers face in implementing payer-to-payer connections has proven to be more substantial than initially anticipated. The need for internal resources and technical expertise is higher than expected, making it difficult to secure the right resources for implementation. For example, establishing a connection between payers requires completing a significant amount of networking and connectivity work. However, simply repeating that process to create a connection to an additional payer isn’t always sufficient and does not create the economies of scale that many hoped for. Instead, the repetitive processes prove to be extremely time-consuming. Availity is attempting to tackle this problem and make connecting to multiple payers easier by creating a one-to-many network with its Connectivity Hub.

Another challenge is the limitations of existing vendor solutions in addressing connectivity challenges. Many vendors focused on providing the internal APIs that a payer would use to respond to a payer-to-payer request. However, this is just one small part of the work that needs to be completed to establish payer-to-payer connectivity. This poses a hurdle for payers who have invested in prior mandates such as Patient Access, where having the API available met the requirements from CMS and are now faced with the need to implement actual payer-to-payer connections with other health plans, without leveraging their previous investments.

Gaps in Implementation Guides

A notable discovery throughout the cohort process was the gaps and inconsistencies uncovered in the Da Vinci PDex implementation guides, which serve as roadmaps for health plans to navigate the process of facilitating payer-to-payer data exchange. Health plans that attempted to establish real-world connections encountered hidden challenges that the guides did not address, adding complexity to the process. For instance, while the guides specify what needs to be implemented, they often lack detailed, step-by-step instructions on effectively executing these implementations, causing confusion and limiting standardization.

Managing implementation workflow changes and dynamic payer catalogs also emerged as a challenge. Health plans might assume they are well-prepared for payer-to-payer data exchange if they have met the requirements for Patient Access, such as migrating data to Fast Healthcare Interoperability Resources (FHIR^®) and developing internal APIs. However, despite having the FHIR repositories to store data, health plans that have met regulatory compliance for Patient Access might not have the proper workflow to effectively retrieve data from another payer. Therefore, unforeseen complexities and necessary modifications could potentially prolong the implementation timeline.

Dynamic Payer Catalogs and Authentication

A final challenge surfaced within the process of dynamic payer catalogs and authentication. Endpoint directories play a critical role in maintaining the accuracy and timeliness of health information across different healthcare entities. These directories act as comprehensive databases that catalog various endpoints—each representing different payers or health plans within a centralized network. However, challenges arise when it comes to managing endpoints, especially for large health plan systems that oversee multiple state-branded plans. Oftentimes, the health plan name familiar to members differs from the parent company name. This discrepancy can make it difficult to keep systems up-to-date and could complicate the process for members trying to find their previous health plan from a dropdown list that displays names of parent companies that members may not be familiar with.

In light of these challenges, it’s essential for health plans to further collaborate and innovate to address these obstacles. As the deadline for mandatory enforcement of payer-to-payer connections approaches, this will require continued partnership, innovation, and a collective effort from all stakeholders involved in payer-to-payer data exchange. 

About the Author

Michael Taylor, Senior Clinical Product Owner at Availity, has over a decade of experience in Health IT. He has successfully navigated roles such as Interoperability Engineer, HL7 Analyst, Product Manager, and Senior Product Marketing Manager. His expertise spans a wide range, including FHIR provider directories, social determinants of health, and electronic consent management. 

Outside of his professional life, Michael enjoys hiking and kayaking. One of his favorite pastimes is modifying and playing with foam blasters (kid’s Nerf toys), dedicating time to enhance their performance and appearance, which showcases his unique blend of technical skills and creativity.