CMS Payer Interoperability 2024
How Are Payers Optimizing the Use of Their Solutions beyond Compliance?

Beyond Compliance, Current Uses of Solutions Most Often Revolve around Data Conversion; Future Use Cases Will Be Focused on EHR Integration & Closing Care Gaps

Currently, over half of interviewed payers are limiting the scope of their interoperability work to CMS compliance. The others who have expanded beyond compliance are mostly large organizations who are using their interoperability solutions for data conversion and translation. On average, these payers report higher satisfaction and more realized value from their solutions.

In the future, customers of all vendors plan to continue their vendor partnership for compliance cases, such as payer-to-payer interoperability and the upcoming CMS-0057 prior authorization regulation. Outside of compliance, many payers need to be able to integrate with multiple EHRs because of their broad member populations—so an agnostic, FHIR-supported integration method is top of mind as a way to ease the resulting administrative cost of data transactions. Another top reported future use case is closing care gaps (e.g., during transitions of care); respondents also mention the potential of analytics and risk/quality metrics to smooth the complex process of payer-provider medical record exchange.

Smile Digital Health Customers Report Highly Varied Use Cases

Interviewed Smile Digital Health customers are mostly large payer organizations with >1 million members, and they report a wide breadth of use cases beyond compliance work, including data conversion and exchange (e.g., ADT data conversion) and EHR integration. Notably, Smile is the only vendor in this report with validated current use cases of care management integration and HEDIS reporting. Respondents feel Smile is an expert in their field because they own the open-source HAPI FHIR (a technology that several other vendors’ solutions leverage) and because the vendor stays up-to-date on FHIR-related updates and implementation guides. However, interviewed customers want better access to the vendor’s expertise through improved training on general FHIR knowledge and on how to optimize and more deeply adopt the solution. Additionally, a few customers say Smile representatives speak too technically in a way that is difficult to understand, and some say the solution is more suitable for advanced users.

Cognizant* has deployed their interoperability solutions to some of their existing TriZetto clients. The few interviewed customers are highly satisfied with the solution’s ability to help meet CMS interoperability mandates. Of the three interviewed customers, two note that it is helpful to have all of the data pieces in one vendor’s system. All three respondents use Cognizant’s solution only for compliance-related use cases and don’t have plans to expand beyond that.

*Limited data

InterSystems Builds Strong Customer Relationships but Has Opportunities to Provide More Product Value; 1upHealth Customers Only Report Compliance Work, with Some Considering Leaving

Often used in conjunction with other InterSystems interoperability offerings, the InterSystems solution is used to meet CMS-9115-F and CMS-0057 regulations. Notably, four out of five responding organizations also report use cases beyond compliance, such as data transaction and integration. Almost all respondents highlight their strong vendor relationship, noting InterSystems’ support team is great to work with and turnaround times are very quick. Customer feedback on training varies—some appreciate the InterSystems training portal, while a few feel the vendor’s training support during implementation is lacking. Additionally, respondents cite a clunky user interface, a lack of functionality (e.g., bulk FHIR exchange, more automated controls), and some difficult upgrades. Some also indicate the high price lessens their ROI, though they point out that they haven’t yet fully utilized the solution. Despite these challenges, most respondents anticipate engaging InterSystems for use cases beyond compliance in the future.

Most interviewed 1upHealth customers say the vendor is easy to engage with as they work together to meet CMS mandates. No respondents indicate any use cases beyond compliance, but most are open to exploring expanded use cases with 1upHealth in the future. Over the past two years, overall customer satisfaction has dropped significantly, driven especially by increased prices that have made it harder for customers to see their money’s worth. A few payer organizations are considering leaving or have decided to leave the vendor, saying it is hard to justify the value of the solution due to the increased price, lack of member adoption, limited used cases, and slow support.

Edifecs & Onyx Technology Customers Highly Satisfied Due to Strong Relationships & Expertise in Compliance

Current Edifecs use cases mainly revolve around CMS compliance, though two customers mentioned also using the solution as an internal translator for various data types, such as X12, HL7, and NCPDP data. Reported future use cases are likewise mostly focused on meeting CMS regulations. Interviewed customers report strong relationships with Edifecs, with some saying they have built their relationship through the use of other Edifecs payer solutions, such as their risk adjustment tool. The vendor is generally considered to be a thought leader with a good knowledge base, particularly around CMS regulations. Responding payers appreciate the vendor’s training programs that not only teach users how to use the solution but also provide education on FHIR. Going forward, customers want to see continued partnership with Edifecs in building out more use cases.

Other Validated Vendors That Provide Payer Interoperability Solutions

In addition to the vendors measured in this report, other vendors also provide interoperability solutions to payer organizations. For example, Epic offers interoperability capabilities in their payer solution, Tapestry. Care management and population health vendors ZeOmega and Zyter also provide interoperability features that can help payer organizations meet CMS mandates. While customer feedback for these vendors is too limited to measure them in this report, KLAS will continue to monitor their performance going forward.

Vendors at a Glance

Fully Rated

Vendors ordered alphabetically

1upHealth

“1upHealth is a flexible and easy partner when it comes to helping us get set up for our interoperability needs and requirements. The vendor is accommodating when it comes to custom integration needs and things like that. That makes working with them straightforward.” —Director

“We are starting to wonder about the vendor’s prices as they relate to the value that we are getting out of the product. As of right now, there is no plan to stop using 1upHealth’s system, but I could see us looking through the market again next year to double-check how much we are paying for the product.” —Director

Edifecs

“The vendor’s people are in all the work groups and are doing a great job. There have been a couple of updates, mostly shoring up the CMS interoperability requirements. The vendor has been a very good partner through all the CMS work. The whole journey has been a very positive experience. Edifecs usually hops on calls within a day or two if we need them. They are very responsive. We have regular check-ins with the VPs that are in charge of our account and all levels of people in the organization.” —Manager

“The vendor could improve at loading the data and do a little more planning and expectation setting for how long things will take.” —Director

InterSystems

“I am highly satisfied with InterSystems, and I really enjoy the level of engagement they bring. Their support has always been very responsive and engaging. One of the pluses that I have seen from InterSystems as an organization has been that they are very proactive in their engagement. They don’t wait to be prompted; they just reach out. They have also been great at bringing everyone, including executives, technical leads, and users, to the table anytime we have needed them to. I have no qualms about recommending the vendor.” —VP

“HealthShare CMS Solution Pack is a big product. It has a lot of bells and whistles. It could be thought of as clunky sometimes. There are a lot of applications to install. It is not an AWS or Salesforce where there is no hardware or other things to maintain and install. That is tough. This product requires servers. InterSystems has moved off of the servers and does have a cloud option, but we are not on the cloud.” —Manager

Onyx Technology

“Onyx Technology is plugged into where the industry is going. I know that the vendor is on a lot of panels that help discuss overall interoperability standards. Onyx Technology has done a pretty good job, and they have a vision of where they think the industry is going and where we need to be.” —CIO

“SAFHIR does what the vendor says it does, but our organization’s integration and interoperability goals are vastly different. SAFHIR isn’t a core solution for our organization, and that isn’t the vendor’s fault. The product plugs the hole that we need it to and supports what we need; it just isn’t a major piece of our goals.” —Manager

Smile Digital Health

“If there is a new implementation guide I need to implement in Smile CDR, all I have to do is download it from the website and install it. We evaluated some products that did not do that, so the advantage of Smile CDR is that we can use it how we want to use it. The product is not built for a particular use case. It is a FHIR-based repository server, and we can use it for compliance-related use cases, value-based care use cases, or interoperable care-related use cases. We aren’t tied into a particular use case, so there are no restrictions.” —Manager

“Smile Digital Health has a good-quality product. They have good-quality documentation. But they don’t offer any good trainers. They would give us technical training, though. If we buy a car, an understanding of the engine is great, but someone has to teach the driver about the features that will affect the safety and performance of the car. The vendor needs to teach us how to use the product not only to be compliant but also to use the product to our advantage so we can have a differentiator in the market.” —Director

Limited Data

Cognizant

“What was unique about Connected Interoperability Solutions was the seamless integration with our core admin system, where most of our data resides. That made the tool very attractive to us because there weren’t a ton of data integration services that had to be performed.” —CIO

“Connected Interoperability Solutions is a technical tool, and we recognize that. However, all interactions with the tool happen from a programming language perspective. I would like a bit more sophistication in the tools. There is no front end for customization or monitoring. We have had to build some of our own processes to monitor data from the data hub. Connected Interoperability Solutions serves its purpose, but it is pretty rudimentary and bare bones. It does what it is meant to do, but I would like to see less involvement from my team in managing the internal workings of the product.” —Director

About This Report

Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 12 months using KLAS’ standard quantitative evaluation for healthcare software, which is composed of 16 numeric ratings questions and 4 yes/no questions, all weighted equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars—culture, loyalty, operations, product, relationship, and value.

Additionally, as part of the standard evaluation, respondents were asked the following supplemental questions specific to CMS payer interoperability:

1. Beyond compliance, what use cases does this vendor currently support for you?
2. Beyond compliance, what use cases do you anticipate this vendor supporting for you in the future?

Sample Sizes

Unless otherwise noted, sample sizes displayed throughout this report (e.g., n=16) represent the total number of unique customer organizations interviewed for a given vendor or solution. However, it should be noted that to allow for the representation of differing perspectives within any one customer organization, samples may include surveys from different individuals at the same organization. The table below shows the total number of unique organizations interviewed for each vendor or solution as well as the total number of individual respondents.

Some respondents choose not to answer particular questions, meaning the sample size for any given vendor or solution can change from question to question. When the number of unique organization responses for a particular question is less than 6, the score for that question is marked with an asterisk (*) or otherwise designated as “limited data.” If the sample size is less than 3, no score is shown. Where textual content relies on limited data, the vendor name is marked with an asterisk. Note that when a vendor has a low number of reporting sites, the possibility exists for KLAS scores to change significantly as new surveys are collected.