2023 Best In KLAS CMS Payer Interoperability

Performance

CMS Payer Interoperability 2022

13 September 22 | Joe VanDeGraaff and Ruirui Sun

CMS recently issued a new regulation stipulating that CMS-regulated payers must be able to securely store and share patient data under the HL7 FHIR standard. To achieve this, organizations use CMS payer interoperability products, which usually provide capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. Health plans and state agencies are evaluating how well technology vendors’ existing or newly developed solutions can help them stay compliant with the new CMS requirements. This report is KLAS’ first to validate the purchase decisions and customer experience of some of the vendors in this area.

To enable patients to securely transfer their data from payer to payer as their coverage changes, new mandates dictate that CMS-regulated payers must be able to securely exchange patient data. Several technology vendors are available to help health plans and state agencies comply with these interoperability requirements, providing capabilities such as patient access APIs, provider directory APIs, and payer-to-payer data exchange. This vendor guide is intended to help health plans and TPAs understand the vendor technology options; it includes those vendors known to KLAS as of July 2022.

In 2021, new CMS rules came into effect that require CMS-regulated health plans to have a patient access API and a provider directory API. Aimed at increasing the interoperability of personal health data, these rules have prompted payers to look at new ways of sharing external information. This report evaluates 1upHealth‘s FHIR Platform, an interoperability solution designed to help payer customers meet governmental regulations and improve consent and authorization management.

Company/solution	Overall performance score (100-point scale)	Total evaluations	Trend (2022-2023)	Culture	Loyalty	Operations	Product	Relationship	Value

Edifecs XEngine Server For FHIR	87.9	n=9	N/A	A-	A-	B	A-	B	A-

1upHealth FHIR Platform	86.8	n=14	N/A	B-	A	B	B+	B+	A

Smile Digital Health Smile Digital Health	84.8	n=12	N/A	B	A-	C+	B+	B	B

InterSystems HealthShare CMS Solution Pack	82.2	n=6	N/A	C+	B	C	B	B+	A-
	50.0	100.0

Company/solution	Trend (2022-2023)	Culture	Loyalty	Operations	Product	Relationship	Value

Edifecs XEngine Server For FHIR 87.9 n=9 COMMENTS	N/A	A-	A-	B	A-	B	A-
1upHealth FHIR Platform 86.8 n=14 COMMENTS	N/A	B-	A	B	B+	B+	A
Smile Digital Health Smile Digital Health 84.8 n=12 COMMENTS	N/A	B	A-	C+	B+	B	B
InterSystems HealthShare CMS Solution Pack 82.2 n=6 COMMENTS	N/A	C+	B	C	B	B+	A-

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