The CMS mandate is easier for some payers and providers than others…here’s why.

The clock is ticking for payers and providers seeking to implement the Centers for Medicare & Medicaid Services (CMS) mandates established in March 2020. While COVID ultimately pushed back the timeline somewhat, the deadline is fast approaching for compliance by July 1, 2021. The major changes? How providers and payers provide patients access to their health information.

It’s wildly overdue. Patients will enjoy improved quality and better outcomes at a lower cost as a direct result of these interoperability mandates. This is the next step to increase transparency, enable greater innovation, and reduce the burden on payers and providers (in theory).  

For healthcare organizations who are already in the midst of digital transformation – this is no problem at all. For those who have not begun any modernization efforts…. the uplift may seem insurmountable.  

In our experience working with some of the largest payers and providers across the nation, we’ve noticed three primary areas that are causing serious pain points in the effort to become compliant.

Barriers to Modernization

Aside from the investment in time and money, there are some key challenges consistently holding payers and providers back from successfully modernizing and meeting compliance with the CMS initiatives:

Challenge 1: Data Access

The first, and perhaps greatest, barrier is access to claims data. There’s a growing tension between consumers needing access to their electronic health records and healthcare organizations providing them the ability to access that information. In reality, many healthcare companies are behind in terms of exposing claims data. More often than not, their systems are limiting and they face barriers ranging from cost and security concerns to an inability to get their legacy systems to cooperate. In a nutshell? These systems are a total pain to work with.

Before any healthcare payer or provider can achieve compliance with the CMS mandates, they must learn how to properly gain access to the data within their claims systems. This fundamental step is necessary to enable interoperability.


Challenge 2: Mapping to FHIR

Over the last several years, CMS as the overlord of government sponsored programs has adopted a slight evolution to HL7 – FHIR is the new standard. FHIR stands for Fast Healthcare Interoperability Resources and was developed by HL7 International. FHIR was intended as a draft data standard meant to define information contents and structure for the core information set that is shared by most implementations. FHIR aims to allow developers to construct standardized applications that permit access to data no matter what Electronic Health Record ‘operating system’ underpins the user’s infrastructure.  

Certain interactions between payers and CMS must be conducted in FHIR, which expands how fast both payers and providers are adopting FHIR in order to exchange information. However, many companies are finding it challenging to map legacy data models to FHIR objects. Part of the complexity is due to inconsistent mapping options. There are a wide variety of “mappings” in FHIR across multiple categories – the lack of consistency between the legacy system and the FHIR standard causes pain for many healthcare organizations. For instance, a number of data models exist in FHIR – perhaps there’s a well-defined data model for a patient – but how do you map the legacy field to FHIR fields?

Challenge 3: Exposing APIs

Once you have the claims data accessible and the data models figured out, there’s a final challenge. You still need to effectively expose APIs in a secure and scalable manner externally. This is a more well-understood technical problem, but most in the healthcare space lack strong data integration strategies. Many opt to build homegrown integration platforms, which in turn makes it more challenging to expose APIs externally.  

IT departments are up against a significant lift to make their APIs accessible – for those who started their move to the cloud, the ask is a bit easier, but it’s still complex while mixing legacy and cloud systems for a period of time.

The Upside – Innovation Through Compliance

Beyond all the sh*t we just talked, there’s a lot of upside for everyone in the process of implementing interoperability initiatives.  

For patients, they will enjoy much easier access to their health records in new and modern ways, have greater ability to shop for care, and increased privacy and security.  

For providers, it will be much simpler and more cost effective to manage patient data requests, they will enjoy greater choice in EMRs, and ultimately will improve patient safety and outcomes.

For payers, it will improve ability to innovate, develop new products, and forecast complex business decisions thanks to API standardization.  


The deadline for CMS mandates are rapidly drawing near. If your organization intends to continue playing in the Medicare/Medicaid space, it is critical to make sure you understand the regulations and their impact to your business.  

For those organizations already in the midst of their modernization efforts, these mandates will be no big deal. For the rest of the healthcare landscape, it’s time to get serious about accessing claims data, mapping legacy systems to FHIR models, and exposing and scaling APIs for external use.

If any of this feels unfamiliar or flat-out terrifying, Concord has resources to help you understand the gaps in your current systems and remedy them. Once in compliance, we can help you take full advantage of your APIs to further innovate and get the most out of your investment.

Download Healthcare Interoperability Case Study