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Three Ways Your Health Plan Can Prepare for Payer-to-Payer Mandate

As a health plan executive, it’s crucial to stay informed and prepared for the forthcoming, Payer-to-Payer mandate, an integral component of the Interoperability and Patient Access Final Rule. This mandate requires payers to facilitate the transfer of member health data from one payer to another via Fast Healthcare Interoperability Resources (FHIR®) Application Programming Interface (APIs) when an individual transfers to a new health plan. In healthcare, APIs are the key to integrating systems from different vendors, enabling seamless sharing of critical patient information, such as electronic health records and lab results. They play a pivotal role in achieving full interoperability by facilitating efficient communication using a common language and standardized structure.

Despite the delays in release and enforcement dates, the Centers for Medicare & Medicaid Services (CMS) is encouraging payers to continue working towards developing the capability to seamlessly exchange member data across the care continuum.

At Availity, we’ve identified proactive steps your health plan can take to help prepare for Payer-to-Payer regulatory compliance:

1. Prepare Legacy Data for FHIR Readiness

CMS is urging payers to remain persistent in their efforts to exchange member data via FHIR APIs. Regardless of potential delays in release and enforcement dates, FHIR offers numerous benefits, including streamlined data access to improve care coordination and enhanced interoperability for tailored interventions. That’s why your health plan shouldn’t postpone evaluating your health plan’s clinical data infrastructure and its ability to convert legacy data sets into FHIR.

The process of converting legacy clinical data sets into FHIR is undeniably a complex and ongoing undertaking. It requires meticulous planning, a robust infrastructure, and adequate resources. To navigate this journey successfully, it is imperative to collaborate closely with IT and data management teams and rigorously adhere to industry standards and best practices throughout the conversion process. To learn how you can ignite your FHIR strategy with high-quality data, download our FHIR eBook.                                                                                                                                                       

2. Compare & Contrast Payer-to-Payer Connectivity Strategies                                                           

If your health plan has an interoperability solution to support compliance with the Patient Access rule, you’re a step ahead. The foundation for the Payer-to-Payer mandate lies in the functionality needed for the Patient Access API. This foundation includes making clinical and claims data available as FHIR and developing the ability to exchange that data with third-party applications through FHIR APIs.

As part of the Payer-to-Payer mandate, you will need to expand on your existing efforts and establish secure connections with other health plans. This will enable you to promptly address member requests to reach out to their previous health plan and retrieve their clinical and claims data. There are a few ways to go about this, some of these options are more labor intensive than others, so evaluating your current capabilities and the resources you have that can support connectivity is important.                                                                   

  • You can reach out to each health plan individually and establish and maintain dozens (or more) of individual connections directly with those payers
  • If any of the health plans you need to connect with utilizes a vendor, you can establish direct connections with each of those vendors.
  • Partner with a Trust Framework Manager that establishes a common set of operating rules and facilitates connections with all the payers you need to engage with

3. Consider Strategic Compliance with Availity

Instead of each payer building their own individual connections, payers might consider collaborating on a centralized hub solution. At Availity, we understand the complexity of trying to facilitate data exchange across multiple data standard types and systems. That’s why we’re diligently working on creating a centralized, one-to-many connection point exclusively designed for health plans. Our goal is simple: to accelerate Payer-to-Payer adherence and streamline data exchange processes. By doing so, we aim to minimize the reliance on costly and time-consuming point-to-point connections.

We have embarked on a dynamic partnership with a select cohort of payers to pioneer the establishment of the inaugural set of payer connections within our cutting-edge connectivity hub. The goal of the cohort is to address two fundamental questions: firstly, to uncover any hidden challenges or pitfalls associated with payer-to-payer connections, and secondly, to determine the most effective and repeatable process for establishing connections with other payers.

By the conclusion of the project, the inaugural cohort members aim to achieve several key objectives including:

  • Seamless exchange of clinical, claims, and authorization data upon member request among cohort members
  • Identify best practices for payer-to-payer implementation and data sharing through the connectivity hub.
  • Prioritize future roadmap items, including the expansion of payer connections to enhance the connectivity hub.

Availity officially initiated its first cohort on August 22, 2023, and maintains regular meetings with participants to collaboratively address pivotal decision points. Furthermore, these participating payers will be engaging in cross-payer data exchange trails facilitated by our connectivity hub. 

If you’re interested in joining a future cohort*, please contact me via email at [email protected].

* Please note, there are certain pre-qualification steps that must be taken for your consideration.