CMS Payer Interoperability Software Product Ranking Comparison

Prior authorizations for referrals and clinical procedures are widely acknowledged as a significant pain point for all involved parties—payers, providers, and patients. Using implementation guides from HL7’s Da Vinci Project, the collaborators in this case study created bidirectional data exchange through a FHIR API that enables an automated, in-workflow authorization process. The pilot use cases have been successful, achieving improved efficiency, reduced costs, and—most critically—more timely care and improved patient outcomes.

Recent Insights

Key Findings:

Executive Summary
The Collaborators
Points of Friction—Challenges to Be Solved
Action Plan—How the Collaborators Worked Together to Reduce Friction
Points of Light—Outcomes Achieved through Collaboration
Lessons Learned—What Best Practices Can Other Organizations Replicate?
What's Next?—Vision for the Future

Performance Data

Overall Score by Product

Overall Score by Question Topic

Provider Facility Size by Product

Provider Facility Type by Product

A new payer interoperability market emerged after CMS announced a mandate on secure patient data exchange, and began enforcing it in July of 2021. Learn more about vendor performance in this follow-up

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.

CMS Payer Interoperability

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