How Are Payer Organizations Finding Value in Their CMS Interoperability Solutions? - Cover

How Are Payer Organizations Finding Value in Their CMS Interoperability Solutions?

In 2020, CMS finalized the CMS-0115-F rule that, among other things, required payers to implement and maintain an API that enables members to access their claims and encounter information. In response, solutions emerged that were geared toward helping payers with CMS compliance, and in 2022, KLAS published our first report on the technology in this space. Since then, use cases for the solutions have continued to develop, branching out even further than the foundational compliance pieces. We recently published an update to the 2022 report, focusing on where the market lies currently, what additional use cases beyond compliance are being used, and how payer organizations are most finding value in their solutions.

Customers Who Utilize Solutions beyond Compliance Find More Value

All of these solutions emerged to meet a specific need—to help payer organizations meet regulations. And that remains the largest priority for payer organizations. Over half of payers in this data set limit the scope of interoperability work with their vendors to CMS compliance. Payer organizations are engaged in large, often expensive contracts with interoperability vendors, and most don’t find that their members are choosing to utilize the APIs. This raises the question of how payer organizations can find more value in a solution they are required to have when member utilization is low.

In response to this question, vendors have developed further technology and some payers (especially larger organizations) have started to expand their use cases. While the compliance pieces are important and foundational to what payers need, data in this report shows that, ultimately, the payers who are using their solutions for more than just compliance are more satisfied and find more value in their solutions. The expanded use cases fit into two main categories: (1) data conversion/ingestion and (2) care management and quality/risk metrics, and some examples of reported use cases include analytics, risk adjustment, and HEDIS metrics. Check out the report to see an extensive list of use cases beyond compliance payers are reporting, broken out by vendor.

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Payer Organizations Need to Work to Build Working Vendor Relationships & Prioritize Data Integration Work

Success in data interoperability for payers comes down, in part, to how much the payer organization puts into their solution. A few vendors in this report were highlighted for their strong relationships and expertise in compliance, ultimately leading to higher customer loyalty and satisfaction—and it’s important to consider that vendor relationships can be strengthened by what payer organizations prioritize as well. It may be easy for an organization to purchase an interoperability solution, check off their compliance needs, and not think much further about the solution or vendor, but that is not the best way to optimize value. Payer organizations have a higher chance of satisfaction and seeing an ROI if they have a good working relationship with their vendor, understand the full capabilities of the vendor’s product, and push to fully leverage those capabilities. Further, future regulations will likely be easier for an organization to meet because of overlap in the expanding work with their interoperability vendor.

On top of building a strong working relationship that can lead to more outcomes, payer organizations need to prioritize data integration in their workflows. Data sharing often takes time to get used to, and it requires practice to be able to broaden integration further. Prioritizing the work allows payer organizations to build trust with all involved stakeholders and allows organizations to optimize their data (in ways such as making sure data is reliable, accurate, and inclusive of necessary items). Ultimately, working with these vendors beyond compliance also leads to improved member care, with many use cases related to care management and risk & quality adjustment.

Think, for instance, what it would be like if an organization bought an EHR to meet Meaningful Use requirements and then let it lie without working with the vendor and optimizing workflows to ensure the best use of the solution—they would end up with a large investment and not many outcomes. In this space, the payer organizations who are proactive about their data exchange and vendor relationships may be much more satisfied and see more member outcomes and ROI.

The Future of the CMS Payer Interoperability Market

In a market born out of necessity in response to regulations, these solutions are already evolving into something more than just tools to maintain compliance. The data in this report highlights the benefits of using an interoperability solution for use cases beyond compliance, and we expect these use cases to continue to grow to help payers best optimize their data and find value in their solutions. We plan to continue tracking the trends and satisfaction in this market, and we will continue following how vendors are supporting new rules like CMS-OO57-F and going beyond minimum compliance to drive meaningful interoperability. Check out the recently published report for more granular details on vendors, customer satisfaction, and use cases.

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