Robert M. Tennant
WEDI Executive Director

 

WEDI has taken on the task of tracking industry progress toward compliance with the Centers for Medicare & Medicaid Services (CMS) Advancing Interoperability and Improving Prior Authorization Final Rule, also known as CMS-0057-F, as we have done for the implementation of X12 Versions 4010 & 5010, and ICD-10. Last week we released the results of our first baseline survey conducted earlier this year on payer, provider, clearinghouse, and health IT vendor readiness, and it yielded some very interesting results.

The 0057 rule mandates several new provisions to increase data sharing, including Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization Application Programming Interfaces (APIs). These new data sharing provisions have the potential for much-needed reduction in overall payer, provider, and patient burden by streamlining prior authorization and improving patient data exchange. Impacted entities are required to implement the API requirements by January 1, 2027. The rule also requires covered payers to publicly report designated prior authorization metrics one year earlier, by January 1, 2026.

The survey questionnaire, developed by WEDI leadership and the WEDI Prior Authorization Subworkgroup, was open to the industry from January to February 2025. Survey responses totaling 243 represented 45% payers, 21% providers, 9% clearinghouses, and 25% vendors.

Key results from the survey include:

Payer Responses:

• For the API requirements, 43% have not yet started work and 31% are 1/4 completed.
• The top three challenges reported are: 1) determining a cohesive enterprise strategy for interoperability; 2) digitizing prior authorization policies; and 3) sufficient funding.
• The majority (35%) estimate a cost of $1 million - $5 million for implementing the API components of the rule.

Provider Responses:

• For the API requirements, 52% reported they had not yet started work.
• The top three implementation issues reported are: 1) sufficient funding; 2) determining a cohesive enterprise strategy for interoperability; and 3) sorting out the various networks and how they interplay (e.g., TEFCA, QHIN, HIE, etc.).
• A majority (44%) are unsure of the total cost for implementing the final rule requirements and training their employees.
• Most (79%) view having the majority of their payers supporting the prior authorization requirements as very important or extremely important.

Clearinghouse Responses:

• A strong majority (84%) intend to assist payers and providers with the API requirements of the rule.
• For the Prior Authorization API, 81% plan to implement both the FHIR and X12 solutions.

Vendor Responses:

• Eighty-one percent plan to assist payers and providers comply with the requirements of the rule.
• Thirty-six percent plan to support consumers with the Patient Access API, while 32% do not.

The survey results suggest that a substantial percentage of both payers and providers have not yet started to implement these API mandates or have only partially completed their implementation efforts. This is understandable. These API requirements are very complex and for many stakeholders, they represent a completely new approach to data exchange. Also, there is a significant amount of uncertainty in today’s health IT environment. Uncertainty can serve to impede forward progress on initiatives requiring significant deployment of resources. When we asked payers and providers what their critical challenges were, it is not surprising that both stakeholder groups identified funding issues, modifying business workflows, and determining a cohesive enterprise strategy for interoperability.

Additional survey results:

• Payers not required to implement the Final Rule were asked if they would be implementing the rule’s requirements, 50% indicated that their organization is currently considering implementing and 50% responded “unsure.”
• The majority of respondents were supportive of staggering implementation of the three prior authorization requirements: Coverage Requirements Discovery (CRD), Document Templates and Rules (DTR), and Prior Authorization Support (PAS), currently all required to be implemented on January 1, 2027.
• When asked which educational options their organization would find the most helpful in their CMS-0057-F Final Rule implementation, the top three cited were education on industry best practices, education on workflow design/modification, and advanced education (technical) on implementing APIs.

As the industry continues to implement this final rule, WEDI will repeat this survey on a regular cadence until the January 2027 compliance date to track the industry’s progress in meeting these requirements. We encourage you to work with us as we leverage the survey data to drive our education, identify industry best practices, and develop policy recommendations.

Access the survey results webinar recording and complete survey results here.