FAQs - Payer Data Exchange
Read the most frequently asked questions on how to meet compliance for the Payer to Payer Data Exchange mandate under the CMS Interoperability Final Rule
FAQs
When do payers need to exchange data with other payers?
When an inactive member has moved to another health plan, the member can request for their data to be exchanged with their current health plan. All payers must have a process in place for members to make this request, as well as the mechanism to send and receive data at their request
Why is Payer to Payer Data Exchange important?
Enabling the sharing of member information between payers helps keep clinical data (USCDI v1) for individual patients together while they switch between health plans. This creates a comprehensive picture of their health that will open new opportunities for improving care.
Currently, the process for requesting data must be defined and implemented by each payer. A new payer should receive information from the member regarding their old health plan to help facilitate the data exchange. That said, CMS is working to identify ways to create an accessible, complete and accurate directory that includes endpoints. They are currently having listening sessions and conducting outreach on this topic.
An upcoming proposed CMS rule “Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information” (CMS-9123-P), suggests that the Payer to Payer exchange will occur at the time of member enrollment and be expanded beyond just clinical (USCDI v1) data. This rule is not yet final; based on the proposed rule it is expected to take effect on January 1st, 2023.
What are the benefits of enabling Payer to Payer Data Exchange?
1. Interoperability: The seamless exchange of member data between payers enables the creation of an up-to-date and comprehensive patient record. This improves administrative and healthcare efficiency by reducing turnaround times and facilitating care coordination and transitions between systems. Ultimately, this leads to:
Improved patient care
Reduced administrative burden
Greater industry potential
2. Patient Empowerment and Improved care: Previously siloed data will now be able to flow seamlessly between payers upon member request. This puts patients in charge of their own information and therefore in control of the future of their personal health. The Payer to Payer Exchange API enables data to follow individual patients across disparate health plans, ensuring that no information is lost. Examples of meaningful data flow:
When a patient ages into Medicare
When a patient changes health plan
When a patient is dually-eligible for both MA plans and Medicaid managed care plans
This patient continuity allows for a comprehensive picture of an individual’s health. This also facilitates informed decision-making, where a patient can choose which health plan to enroll with. Patient empowerment ultimately enables individuals to more effectively manage their own health, care and costs. Together, improved data flow, patient continuity, and empowerment improve health care outcomes.
3. Reduced Administrative Burden: The increased automation enabled by the use of a specialized Payer to Payer Data Exchange API reduces the administrative burden for both payers and providers. For payers, work and cost-efficiency is improved. For providers, high-quality coordinated care is made possible.
4. Broader Industry Potential: Payer to Payer Data Exchange is built on top of the Patient Access API rule. This means that years of health care data, that was made available through the Patient Access API, can now be exchanged between payers and enable:
Minimization of burdens Cost reduction
Transparency between payers and patients, who can access the same information within the same time-frame
Creation and maintenance of a comprehensive health record
Together, these will broaden industry potential. It will be possible to introduce analytical capabilities through which both payers and providers can gain valuable insights that will ultimately open new frontiers in health care.