Jun - 19
Article
Payer-to-Payer rule - Understanding the mandates
Impacted Payers including Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) must comply to the Payer-to-Payer Data Exchange API Rule, by January 1, 2027. The rule mandates that Payers share member data with other current or concurrent Payers when coverage begins and on a quarterly basis if the member has multiple Payers. Impacted Payers are mandated to share at least five years of member data rather than the full record. Unlike the previously proposed rule which required Payers to share only clinical data of their members, the 2024 final rule has mandated sharing holistic member health information including clinical data, adjudicated claims, encounter data, cost-sharing information, and prior authorization details, while requesting for the chosen Health Plans.
Context behind the rule: Challenging the past and ensuring a promising future
CMS recognized that as members transition between different health plans, their medical data often remains siloed within each Payer's systems, hampering care continuity and coordination. Providers lack a comprehensive understanding of a member's medical history, potentially leading to redundant tests, inappropriate treatments, or adverse events. Members endure the frustration of repeating their medical history to every new Healthcare entity, while Payers grapple with inefficiencies and increased costs due to fragmented data. To bridge this gap, CMS has outlined requirements for Payers to share relevant member information with current or concurrent plans, fostering a longitudinal view of an individual's health journey. Providers can now access a member's complete health record, facilitating informed decision-making and personalized care. Members will enjoy the convenience of their data following them seamlessly, reducing redundancies and enhancing their overall Healthcare experience. Payers will gain valuable insights into their members' health histories, enabling better risk management, care coordination, and cost optimization.
Payer investment drivers and opportunities
While the rule aims at improving care continuity and coordination, it does not mandate Payers to request member data from prior or concurrent Health Plans. So, even though the recommended Da Vinci PDex IG outlines the steps and framework for bi-directional data exchange between requesting and data sharing among Payers, for compliance purpose, Payers are recommended to follow the Da Vinci PDex IG to share member data with a requesting Payer in a fast and accurate manner.
Keeping this in mind, it would be convenient to assume that Payers will have two distinct drivers to invest in P2P data exchange solutions: 1) to achieve regulatory compliance and 2) to enhance care continuity and coordination. Keeping regulatory compliance as the baseline requirement, impacted Payers are mandated to build an infrastructure to share requested member data with the requesting Health Plans. Payers can leverage the same FHIR-based solution that was built for Patient Access API, as per CMS Interoperability & Patient Access Final Rule (CMS-9115-F). Additionally, this will involve mutual authentication with other Payers to enable secure data sharing, member consent validation, and member matching operation capabilities.
However, forward-thinking Payers will recognize the opportunity to leverage the CMS mandate to foster a more collaborative Healthcare ecosystem. By investing in bi-directional data exchange capabilities, Payers can request and access members' historical data from previous plans, enabling seamless care transitions and comprehensive care coordination. This objective will require Payers to invest in a platform solution enabling the onboarding of Health Plans, bundling of member data to facilitate member match, and retrieval of bulk historical data using standards-based APIs and data models.
Step by Step Guide to Payer-to-Payer Data Exchange
