A Reprieve for Payers: CMS announced it will not enforce payer-to-payer requirements

Authored by: Ngan MacDonald


While healthcare payers have all struggled with the Patient Access API requirements for payers to provide a patient’s data to third-party apps this July, another requirement for making that data available to other payers was looming ahead for payers on 1/1/2022. That suspense was removed on September 15th and replaced with some certainty and more questions. In their announcement, CMS released guidance on the enforcement of the payer-to-payer exchange for 1/1/2022. Essentially, they have received feedback from the industry that the current standards that would guide how this functionality is enabled is not scalable. As such, they are not enforcing the deadline for this until after they have had the opportunity to finalize the proposed burden reduction rule. Below is the FAQ that was issued:

37. Question. Will CMS enforce the payer-to-payer data exchange requirements on January 1, 2022 as finalized in the CMS Interoperability and Patient Access final rule?

Response. No. CMS is exercising its discretion in how it enforces the payer-to-payer data exchange provisions (85 FR 25564-25569) of the CMS Interoperability and Patient Access final rule (CMS-9115-F). As a matter of enforcement discretion, CMS will not take action to enforce compliance with these specific provisions until future rulemaking is finalized. CMS’s decision to exercise enforcement discretion for the payer-to-payer policy until future rulemaking is finalized does not affect any other existing regulatory requirements and implementation timelines finalized in the CMS Interoperability and Patient Access rule finalized on May 1, 2020. CMS continues to encourage impacted payers that have already developed Fast Healthcare Interoperability Resources (FHIR)-based application programming interface (API) solutions to support payer-to-payer data exchange to continue to move forward with implementation and make this functionality available on January 1, 2022 in accordance with the CMS Interoperability and Patient Access final rule policies. However, for those impacted payers that are not capable of making the data available in a FHIR-based API format, we believe this enforcement discretion will alleviate industry tension regarding implementation; avoid the risk of discordant, non-standard data flowing between payers; provide time for data standards to mature further through constant development, testing, and reference implementations; and allow payers additional time to implement more sophisticated payer-to-payer data exchange solutions.

You can also find this guidance here: https://www.cms.gov/faqs#122

We at HealthLX believe that the current proposed burden reduction rule has outlined requirements for a provider access API that will function in a similar way to the payer-to-payer exchange and once this rule is finalized, it will put into place the need for bulk transfer technology to make the business-to-business transfer of data scalable. The standards for this more robust approach to business-to-business data transfer are expected to be balloted and published in 2022. Given the immaturity of the standards, our recommendation to our clients was to pause the technical implementation of payer-to-payer efforts until the new final rule is published.

There are some who question the practical aspects of implementing a payer-to-payer exchange and will take this opportunity to scrap work in this effort. However, the reality is that the healthcare industry needs the mechanism to exchange data between business entities and the standards that the FHIR at Scale Taskforce (FAST) are working on will enable our industry to make meaningful progress in the right direction. My advice to our friends and colleagues is that we need to pause, consider what is coming up ahead, but please, for the sake of healthcare interoperability, don’t stop.


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