Survey Finds Slow Start on CMS Interoperability Rule Implementation

With deadlines looming in 2026 and 2027 for compliance with the CMS Advancing Interoperability and Improving Prior Authorization Final Rule, a WEDI survey indicates a concerning lack of readiness among payers and providers to meet the new API requirements for data sharing. | Image Credit: Postmodern Studio - stock.adobe.com

A significant portion of payers and providers have not yet begun or are only partially through implementing the application programming interface (API) requirements mandated by the CMS Advancing Interoperability and Improving Prior Authorization Final Rule (CMS-0057-F), highlighting concerns around funding, strategy, and workflow adjustments, according to a Workgroup for Electronic Data Interchange (WEDI) survey.¹

The rule requires various new provisions to increase data sharing, such as APIs supporting patient access, provider access, payer-to-payer, and prior authorization. Impacted entities must implement the API requirements by January 1, 2027, and the rule requires that covered payers publicly report designated prior authorization metrics.

In 1991, Louis Sullivan, MD, the HHS secretary at the time, developed WEDI to identify opportunities to improve the efficiency of health data exchange. It now focuses on the use of health information technology to improve information exchange, enhance care quality, and reduce costs.

These new data sharing solutions could allow for necessary reductions in overall payer, provider, and patient burden by streamlining prior authorization and improving patient data exchange, but the findings reveal a slow start to the overhaul of data workflows. “WEDI plans to repeat this survey on a regular cadence until the January 2027 compliance date to track the industry’s progress in meeting these requirements,” Robert Tennant, WEDI executive director, said in the press release.

There were 243 survey responses: 45% were from payers, 21% were from providers, 9% were from clearinghouses, and 25% were from vendors. For the API requirements, payer responses indicated that 43% have not yet started work and 31% are a quarter completed. A plurality (35%) of payers estimated a cost of $1 million to $5 million for implementing the API components of the rule. Determining a cohesive enterprise strategy for interoperability, digitizing prior authorization policies, and sufficient funding were among the top 3 challenges reported by payers.

Provider responses for the API requirements revealed 52% who reported they had not yet started work. A plurality (44%) reported they are unsure of the total cost for implementing the final rule requirements and training their employees. Most providers (79%) viewed having many of their payers supporting the prior authorization requirements as very important or extremely important. The top 3 implementation issues were sufficient funding, determining a cohesive enterprise strategy for interoperability, and sorting out the various networks and how they interplay.

The survey found that a strong majority of the clearinghouse respondents (84%) intend to assist payers and providers with the API requirements of the rule. For the prior authorization API, 81% plan to implement both the Fast Healthcare Interoperability Resources (FHIR) and X12 solutions.

FHIR is a standard method for exchanging health care information electronically and provides a way to share information among clinicians and organizations regardless of how local electronic health records represent or store the data.² Similarly, X12 allows US companies to communicate information and transfer documents from business to business without the barriers of incompatible software or unsecure connections that may leave data vulnerable to outsiders.³

“The survey results suggest that a substantial percentage of both payers and providers have not yet started to implement these API mandates, or have only partially completed their implementation efforts,” Tennant said.¹

Vendor responses included 81% who plan to assist payers and providers comply with the requirements of the rule. There were 36% who planned to support consumers with the patient access API, while 32% did not.

Half of the payers that were not required to implement the Final Rule indicated that their organization is currently considering implementing while the other half were unsure. Most respondents were supportive of staggering implementation of the 3 prior authorization requirements, including coverage requirements discovery, document templates and rules, and prior authorization support. Organizations expected the 3 educational options that would be the most helpful for their CMS-0057-F Final Rule implementation were education on industry best practices, education on workflow design/modification, and advanced education on implementing APIs.

“These API requirements are very complex and for many stakeholders, they represent a completely new approach to data exchange. It is not surprising that identifying funding, modifying business workflows, and determining a cohesive enterprise strategy for interoperability were cited by many as critical challenges,” Tennant stated.

References

1. WEDI survey finds payers and providers facing significant challenges in meeting CMS interoperability and prior authorization requirements. Press release. WEDI; April 9, 2025. Accessed April 10, 2025. https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:9a17c76a-ef81-4a3e-8624-6dc1bcf54755

2. Fast Healthcare Interoperability Resources. eCQI Resource Center. August 9, 2024. Accessed April 10, 2025. https://ecqi.healthit.gov/fhir?qt-tabs_fhir=about

3. X12 EDI basics: a guide to the X12 standard. CData Software. Accessed April 10, 2025. https://arc.cdata.com/resources/edi/x12.rst