The Journey Toward More Consumer-Centric Care

posted by Inovalon

on April 13, 2021

Interoperability & the Future of Healthcare Data & Decisions


With the introduction of HIPAA in 1996, interoperability has often taken center stage in the healthcare arena. Amid new Federal regulatory requirements and an unprecedented  global pandemic, the importance of the industry’s journey to achieve a truly interoperable and connected healthcare delivery system that supports improved patient care and quality outcomes has never been clearer.

Payers and providers have been working together for years, alongside healthcare interoperability collaboratives such as The DaVinci Project, CARIN Alliance, CommonWell Health Alliance, Carequality and The Sequoia Project, on the most effective ways to collect and share data. However, payers are now facing new Federal mandates to exchange claims and clinical data with members and third-party applications of their choosing as well as other payers. This became a requirement for plans within Federal programs under the Centers for Medicare & Medicaid Services’ (CMS’s) Interoperability and Patient Access Final Rule in March 2020.

These requirements are far from the end of the Federal Government’s efforts to establish a more connected and transparent healthcare delivery system. In fact, they mark only the beginning of a much broader effort laid out by the Federal Government for implementation at an accelerated pace reaching every facet of the healthcare interoperability realm. The rapidly expanding regulatory landscape and evolving standards development have spurred confusion among healthcare stakeholders in how best to achieve compliance safely, effectively and efficiently.

At the tail end of last year, the Interoperability and Prior Authorization proposed rule sought to apply new requirements on certain plans in Federal programs to also share data seamlessly with providers. While the final rule is on hold as part of the new Administration’s regulatory freeze, it is expected that the main intent of each of the regulatory mandates finalized over the past year will remain intact. In addition, Commercial plans subject to the Transparency in Coverage final rule must share pricing information with members via web-based tools and with other healthcare stakeholders via machine-readable files. Moreover, the ‘No Surprises’ Act requires commercial plans to connect with providers to generate a price check for members before care is furnished.

As stakeholders work to meet the vast range of upcoming Federal regulatory deadlines between the middle of this year through 2024 and beyond, this white paper explores the ongoing journey healthcare organizations, specifically healthcare payers, are on to advance interoperability, connectivity and consumer access within an industry that has often lagged others in its digital transformation