WEDI Survey: Industry Readiness for CMS Interoperability and Prior Authorization Rule Results

Details

WEDI conducted a baseline survey to assess the healthcare industry's readiness for the CMS Advancing Interoperability and Improving Prior Authorization Final Rule (CMS-0057-F). This rule aims to increase data sharing through new provisions, including Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs, thereby streamlining prior authorization processes. The survey, conducted from January to February 2025, received 243 responses from various entities. Key findings show that a significant portion of payers (43%) have not yet started work on the API requirements, citing challenges like determining an enterprise strategy and securing funding. Similarly, 52% of providers have not begun working on the API requirements, identifying issues such as sufficient funding and navigating complex network interrelationships (e.g., TEFCA, QHIN, HIE). Despite these hurdles, clearinghouses showed strong support, with 84% planning to assist payers and providers. Regarding the Prior Authorization API, 81% of clearinghouses intend to implement both FHIR and X12 solutions. Vendors also plan to provide assistance (81%). Furthermore, a majority of respondents supported a staggered implementation approach for the three prior authorization requirements (CRD, DTR, PAS), which are currently due by January 1, 2027. Overall, the results indicate that while industry support and technical intent are high among certain groups (e.g., clearinghouses/vendors), the majority of payers and providers face substantial strategic, financial, and operational challenges in meeting the mandated interoperability standards.