CMS delays enforcement of key interoperability requirement of payer-to-payer data exchange

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Insurers have slammed a key part of a Centers for Medicare & Medicaid Services interoperability rule that requires payer-to-payer data exchange for lacking specificity. (ipopba/GettyImages)

The Biden administration has delayed enforcement of payer-to-payer data exchange included in a May 2020 final interoperability rule until future regulations are finalized.

The decision by the Centers for Medicare & Medicaid Services (CMS), announced Wednesday, comes after the insurance industry has warned that the final rule was hastily constructed.

“CMS’ decision to exercise enforcement discretion for the payer-to-payer policy until future rulemaking occurs does not affect any other existing regulatory requirements,” according to the notice from CMS.

The interoperability rule, finalized in May 2020, required CMS-regulated payers such as Medicare Advantage plans, fee-for-service programs, Medicaid managed care and Children’s Health Insurance Program fee-for-service programs to implement and maintain an application programming interface (API) for sharing data with apps.

Payers were also facing a Jan. 1, 2022, deadline to implement a part of the rule that requires payer-to-payer data exchange at the patient’s request for any plan or policy years starting on or after Jan. 1, 2022. But insurance groups cried foul that the rule will require payers to install technology with incomplete requirements.

“This administration requires insurance providers to build expensive IT bridges to nowhere by failing to establish comparable requirements for providers or their IT vendors to use the technologies,” said Matt Eyles, president and CEO of insurance group America's Health Insurance Plans, in a statement back in January.

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CMS announced Wednesday that the agency will not enforce compliance with the payer-to-payer exchange until future rulemaking is finalized.

The Trump administration aimed to clarify how payers had to exchange this information in a proposed rule in December 2020, but it has not yet been finalized since administrations changed hands a month later.

If a payer has already started to develop API solutions to prepare for the rule, they should continue to move forward and make the payer-to-payer exchange functionality available by the start of next year.

But the payers who are not capable of making the data available in the API format will not face enforcement.

“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,” the agency said in a new FAQ document.

CMS added that in the interoperability final rule, the agency didn’t require a specific mechanism for payer-to-payer data exchange.

“Since the rule was finalized in May 2020, multiple impacted payers have indicated to CMS that the lack of technical specifications for the payer-to-payer data exchange requirement is creating challenges for implementation, which may lead to differences in implementation across the industry, poor data quality, operational challenges and increased administrative burden,” CMS said in the FAQ posting.