Applying lessons from earlier CMS-9115-F interoperability rule

By Gokul Varadharaj, Chief Revenue Officer & Co-Founder
Vincent P. Tumminello, AVP, Solution Strategy
Dmitri Kitaynik, Director, Product Management

Payers can apply lessons from implementing CMS-9115-F to tackle the significantly more ambitious and complex interoperability and prior authorization final rule, CMS-0057-F. This latest mandate is a golden opportunity for payers to realize strategic value for members, providers, and underlying business performance, value that extends well beyond mandated compliance.

Implementation of its predecessor, CMS-9115-F, did not deliver fully on the mandate’s expected outcomes, namely broad use and adoption of patient access to their health information and greater interoperability of healthcare data, due to multiple factors including:

• Low member adoption and engagement
• Variable maturity in payer data integration and standardization capabilities that made sharing usable data difficult
• Ambiguous regulatory clarity and guidance
• Operationalizing FHIR standards in legacy systems not designed to support them

Payers invested heavily to meet the earlier mandate and many plans continue to maintain expensive solutions, but investments have delivered limited business value beyond compliance. With the new CMS-0057-F rule, payers can rewrite their playbooks to achieve compliance at a lower total cost of ownership while driving greater strategic business performance for their organization.

With the stakes considerably higher in this second round of CMS interoperability, payers have a chance to achieve a value trifecta: Compliance with CMS-0057-F, use case extensibility, and lower total cost of ownership. The key is starting with a flexible usable data foundation.

CMS-0057-F implementation challenges

CMS-0057-F is a mandate with interoperability ambitions well beyond compliance given its scale, scope, and potential to drive improvements in member and provider experience and care delivery. This rule is between 5 and 10 times more complex than CMS-9115-F, with payers up against a 2027 deadline that requires operationalizing Fast Healthcare Interoperability Resources (FHIR) APIs that:

• Expand patient access to include richer, clinical histories
• Support payer-to-payer electronic data exchange
• Support payer-to-provider electronic data exchange
• Improve their prior authorization process and move it within a provider’s electronic health record solution

Putting additional pressure on implementation is the federal deadline of March 31, 2026, requiring payers to deliver initial patient access reporting metrics to CMS and some states, including Washington, requiring compliance for aspects of the mandate as soon as January 2026 – a year earlier than CMS.

These investments come at a time when payers are facing significant financial headwinds, notably medical loss ratio (MLR) reaching a 13-year high, driven by a combination of increased utilization, higher medical cost trends and overall cost of care. Prioritizing a CMS-0057-F solution that lowers total cost of ownership and optimizes efficiencies is imperative.

Usable data catalyzes value beyond CMS compliance

The foundation for CMS compliance, broader healthcare data interoperability, and other important use cases is usable data – accurate, complete, timely, relevant, versatile and formatted and ready for any application or use case.

Fortunately, usable data required to operationalize CMS-0057-F, including medical and pharmacy claims, encounter data, and lab results, can be repurposed for use cases beyond compliance such as quality, risk adjustment, and population health/value-based care. To support quality and risk adjustment efforts, for example, making encounter data usable would enable personalized member and provider outreach to close gaps in care.

Best practices for optimizing CMS-0057-F compliance

Given the challenges and opportunities in implementing CMS-0057-F, payers should adopt the following best practices to achieve full compliance while creating opportunities to unlock additional business value and lowering overall total cost of ownership.

1. Evaluate your CMS-9115-F solution. Will your previous investments and internal team be able to scale up to meet the more complex CMS-0057-F mandates? Many solutions were developed to support partial compliance with the CMS-9115-F mandates, but compliance with CMS-0057-F may require a multi-vendor or different turnkey solution. Building around subscale, non-compliant CMS-9115-F solutions is likely to lead to an inefficient solution with hidden operational and infrastructure costs.

2. Maximize FHIR-based architecture. Design and implementation of a FHIR-based interoperability solution should maximize the enterprise potential of this substantial investment and minimize the costs of translating and transforming data into this format. FHIR has a future in healthcare interoperability, so payer IT and operational leaders should align their roadmaps to ensure a cohesive strategy.

3. Seek out expert partners. Many payers don’t have the luxury of time for a completely internal build. Seek partners that complement your internal resources based on prioritization of capabilities that should be nurtured in-house. Consider partners that bring a combination of subject matter and technical expertise and flexibility in their implementation approach. Partners with these capabilities can accelerate the “buy” value of a buy + build strategy with streamlined implementation and faster time-to-business value.

4. Go modular to enable other business use cases. By implementing modular CMS-0057-F capabilities, payers can seamlessly add to the same data chassis, solving for CMS-0057-F compliance while addressing business use cases for quality/HEDIS/Star Ratings, risk adjustment, cost of care and other core organizational functions. This approach to modularity also makes it easier to extend interoperable data exchange via FHIR APIs to commercial plans. This approach delivers the strategic trifecta for complying with CMS rules while optimizing business value: Scalability, extensibility, and affordability.

5. Insist on a foundation of usable data. Instead of continued one-off, conversion-focused extracts, leverage this mandate to modernize the enterprise data foundation and data management. Getting the data layer right makes all the difference in superior technology performance to drive operations and analytics. The premier standard is usable data that is accurate, complete, timely, relevant, versatile, and formatted and ready for specific use cases and applications.

6. Build for long-term competitiveness. Payers that invest in and leverage a more versatile interoperable data foundation can gain market share by reducing expenses and improving provider relationships, member experience and business performance.

By focusing more strategically on achieving value beyond compliance, payers have an opportunity to rewrite their compliance and interoperability playbook to achieve cost efficiency related to CMS-0057-F implementation while simultaneously upgrading their data foundation and interoperability capabilities to unlock innovation and business performance.

Abacus Insights can help payers no matter where they are in their CMS-0057-F journey. Seamlessly achieve compliance with CMS-0057-F, the CMS mandate, at the lowest total cost of ownership and get greater value from your investments.

Abacus Insights’ CMS Interoperability Data Solution

Abacus Insights’ CMS Interoperability Data Solution meets payers where they are in their CMS compliance journey. Built on Abacus’ usable data platform for payers and fully integrated with Onyx CMS interoperability expertise, the solution provides a suite of turnkey compliance modules enabling payers to seamlessly and cost-effectively achieve compliance with the current CMS-9115-F mandate and accelerate implementation and compliance with CMS-0057-F.

Please contact us at info@abacusinsights.com to discuss how we can support your CMS interoperability efforts.