Nov 8, 2022

CMS Interoperability Mandate for Payers and Providers: Seeing an Opportunity in Necessity

CMS’s Interoperability Mandate for Payers and Providers: Seeing an Opportunity in Necessity

CMS Interoperability Mandate for Payers and Providers: Seeing an Opportunity in Necessity

Healthcare consumerism is growing at an unprecedented rate, and there is an increased focus on empowering consumers to take greater control of their health. Transparency, access, choice & convenience are the four corners of consumerization of any vertical and we are seeing this play out in healthcare as well. Information transparency be it cost, quality or other data depends on true interoperability. Healthcare has traditionally suffered from a lack of true interoperability and this is finally beginning to change.

The Imminent Compliance Need

Realising the importance of true interoperability over the last few years, CMS finalized the first rule dedicated to interoperability with its CMS Interoperability and Patient Access final rule in May 2020. The rule requires Medicare & Medicaid Payers and Providers to give FHIR API-based access to a consumer’s (member or patient) data. Under the rule, health plans and providers must enable their consumers to use third-party apps and standard APIs to access claims, medical records, provider & pharmacy directories and formularies information.

Simply put, the rule calls for giving consumers easy access to their health data and establishing governance frameworks for facilitating exchange of healthcare information securely & conveniently. The rule which mandates compliance starting July 1, 2021, created an urgency and set the stage for digital transformation on FHIR.

Mandate v/s Opportunity: The choice is yours!

As this deadline looms, payers & providers have an interesting choice to make: (i) Either approach this mandate as a compliance necessity or (ii) Turn the compliance need into an opportunity to better engage with their consumers and differentiate themselves in the industry.

Organizations approaching this as a mandate necessity can very quickly cobble together a solution that meets the requirements checklist. However, I believe this is akin to seeing trees and missing the forest – i.e we miss a big opportunity to maximize value of our compliance investments and drive better consumer engagement

Can we have a platform driven approach to compliance – i.e not just to 9115F but also 9123F or 9915F?

Such an approach helps organizations improve the ROI on these investments. Solutions that consider this will future proof their design. A bit of foresight goes a long way in reducing waste.

Can we make it easier for consumers to not just access their data but leverage it for a better experience?

According to a brief by the Office of National Coordinator for Health IT (ONC), only 60% of all hospitals use a health information exchange for data sharing [1]. Various types of interfaces, growing data sources and lack of a uniform standard has only complicated this further. Inability to access outside health records and complexities related to care coordination across several networks leads to patients repeating tests, costing the nation upwards of $210 billion [3] on excessive and unnecessary treatment. Delay in care delivery is another significant impact.

Even in ambulatory and primary care settings, information gaps exist. For example, we know providers do not always have the complete medication history for patients. This sometimes results in sub-optimal care and complications. Giving consumers the ability to create a unified record and share it with caregivers and providers can make their life easier, while improving the quality of care delivered.

“If we continue on our present path, by 2026 we will be spending one in every five dollars on health care! [2]”

– Seema Verma, ex-CMS Administrator

Sharing structured benefits & claims data can now open up opportunities to inform consumers about the financial implications of their care choices (e.g high out-of-pockets, in-network vs out-of-network) which will help them make better decisions for themselves and their families.

Can we expand on the inter-connectivity beyond data into services?

COVID-19 accelerated digital health adoption as more payers and providers turned to digital health options out of necessity, in turn triggering adoption of digital health enmasse by consumers. The big side effect of this mandate will be greater digital engagement with consumers. When consumers are more engaged – whether it is to look at their data in the mobile application they like or to access services conveniently, payers & providers win because the greater mindshare can be leveraged to more effectively engage with consumers (e.g greater engagement with online surveys & care plans, telephonic care management augmented with electronic aids and so on). Solutions that can foster real-time connectivity with mobile applications and systems of record inside payers & providers are well positioned to drive better consumer engagement.

The Road Ahead

This is an unprecedented opportunity to create a better healthcare eco-system for all – for consumers, for payers & providers.  With the CMS 9115-F mandate, the stage will be set for digital transformation and true interoperability to drive the next generation of consumer-focused healthcare systems. We will see a plethora of innovative solutions that leverage this transparency to deliver convenience, choice & access. I believe the organizations that recognize the strategic impact of this rule will leverage the opportunity to position themselves well in a consumer driven healthcare system.

Message from Mpowered Health

Mpowered Health has developed a comprehensive CMS interoperability compliance platform for payers and providers. Our platform enables payers and providers serving Medicare & Medicaid to quickly & efficiently comply with the CMS 9115-F, Interoperability and Patient Access final rule by ensuring seamless and secure payer data connectivity and supporting FHIR server and open API gateway based on HL7 FHIR v 4.0.1.

Acknowledging that small payers and providers are more likely to face resource constraints to meet this important compliance need, we’re providing our CMS 9115-F compliance solution at zero cost to all payers and providers serving less than 5000 members/patients in their network.  Larger payers and providers can also see significant ROI from this solution.

To learn more about our CMS interoperability compliance platform, reach out to us at


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