The implementation of the interoperability and prior authorization final rule is a crucial step towards improving health information exchange and moving the industry towards electronic prior authorization. However, a recent survey conducted by the Workgroup for Electronic Data Interchange (WEDI) has revealed that more than half of providers and 43% of payers have yet to start work on the application programming interface (API) requirements of the final rule.
The WEDI baseline survey shows that many providers and payers are lagging behind in implementing the requirements set forth by the Centers for Medicare and Medicaid Services (CMS). The rule, which was released in January 2024, has provisions that take effect in 2026 and 2027. Despite the looming deadlines, a significant percentage of stakeholders have not even started implementing the API mandates, citing challenges such as funding and training costs.
One of the major hurdles for payers is the cost associated with API implementation, with 35% estimating a cost between $1 million and $5 million. Providers are also concerned about funding, with 44% unsure of the total cost for implementing the final rule and training their employees. Clearinghouses and vendors, on the other hand, are prepared to assist payers and providers in complying with the requirements of the rule.
The survey results indicate that there is a lack of progress in meeting the API requirements, with many stakeholders either not started or only partially completed their implementation efforts. Despite the challenges, the majority of respondents support staggering the implementation of the three prior authorization requirements: Coverage Requirements Discovery (CRD), Document Templates and Rules (DTR), and Prior Authorization Support (PAS).
To track the industry’s progress in meeting these requirements, WEDI plans to repeat the survey on a regular basis until the January 2027 compliance date. The survey, which received 243 responses from payers, providers, clearinghouses, and vendors, highlights the need for educational resources and support for stakeholders as they navigate the complexities of the final rule.
In conclusion, the interoperability and prior authorization final rule presents a significant challenge for the healthcare industry. Stakeholders must prioritize implementation efforts to ensure compliance with the requirements set forth by CMS. With the support of clearinghouses, vendors, and industry organizations like WEDI, stakeholders can work towards improving health information exchange and streamlining the prior authorization process for better patient outcomes.
