4 Big Changes For Payers Going Into Effect in 2021 (and How to Prepare for Them)

Exponential Health, the Final Rule

ONC’s Final Rule is going into effect this year. Here are the four big changes payers will need to anticipate.

Last March, the Office of the National Coordinator (ONC) released the much-anticipated “Final Rule” of the 21st Century Cures Act to drive interoperability and data access for patients, Providers, and Payers. The original intention was for the Rule to go into effect last year, but like everything else in the world, these plans were disrupted by COVID-19, so the ONC adjusted its time frames and requirements into this year and beyond. 

Exponential Health, logo

The Final Rule includes many of the well-documented provisions focused on promoting API adoption and curbing information blocking; however, there is much more for Payer organizations to consider. In this post, we’ll explore four critical implications of the Rule and how they will impact Payer organizations specifically:

  1. Patient Access through API

  2. Provider Directory APIs

  3. Payer-to-Payer Data Exchange

  4. Public Reporting and Information Blocking 

The Rule will require Payer organizations to fundamentally reassess their digital infrastructures and develop strategies to support new digital functionality.

The Rule will require Payer organizations to fundamentally reassess their digital infrastructures and develop strategies to support new digital functionality.

That being said, the Rule’s intent is not solely to accelerate interoperability and better-coordinate care but also to reduce barriers and costs across the industry. Forward-thinking Payer organizations will use the Rule as an opportunity to build new services, recalibrate existing cost-drivers, and take advantage of this new healthcare paradigm. Let’s dive in.

Patient Access through APIs

The Rule will compel CMS-regulated Payers to make encounter and claims data available via APIs, effective July 1, 2021. This is a move toward greater transparency and interoperability will impact Payers’ operations and lead to enhanced coordination with downstream patient device manufacturers and applications (e.g., Apple Health, remote patient monitoring devices, and other third-party services). 

Payer organizations need to work quickly to evaluate their current technology ecosystem and build a strong foundation for building open-access APIs for general use. However, this is also an opportunity for Payers to reassess their internal care coordination approach and deliver tailored services for patients with added clarity and transparency.

Provider Directory APIs 

Although many Payer organizations already have Provider repositories accessible to the public via a user interface (i.e., find-a-doctor search), they will also need to make these directories accessible via API, effective July 1, 2021. This change is important to consider because many existing Provider directories are built on legacy systems that make it difficult to expose APIs and build new value-additive services (e.g., appointment scheduling and management). 

Learn about some of the ascendent trends in healthcare and how digital technologies are helping address them. 

Some Payers will need to take on a significant transformation initiative to prepare their digital infrastructures to meet the needs of a quickly changing landscape. This may mean taking a completely new digital approach and investigating new technologies like no-code to integrate their legacy systems with modern digital experiences. ;)

Payer-to-Payer Data Exchange 

As of January 1, 2022, if a patient requests to share their information, CMS-regulated Payers are required to transmit that data in accordance with the United States Core Data for Interoperability (USCDI) format. The USCDI format includes data elements such as patient demographics, care team members, immunizations, and more (the full list can be found here). 

Payers will need to develop the ability to efficiently collect information, translate it into USCDI format, and securely transmit it to relevant external systems. As a result, we also expect to see new data enrichment services take shape over the next several years. 

Public Reporting and Information Blocking

The Rule requires the industry to crack-down on information blocking and support higher-frequency public health reporting. This will break down the information-sharing barriers between organizations and facilitate an aggregate view of community health.

Payers will need to update their data-reporting to Health Information Exchanges from a monthly cadence to daily. To do this efficiently (and affordably), Payers will need to automate high-volume tasks related to data collection and transmission. 

This stipulation aims to promote population health, care coordination, and the social determinants of health.  

The Final Rule is designed to empower patients with greater transparency into services and guarantee the ability to move their data freely across the healthcare ecosystem. While these changes may lead to some short-term challenges for Payer organizations, they should also be viewed as opportunities to increase operational efficiency and build new patient services.

To learn more about the nexus of health and technology, check out other recent entries in Exponential Health.


About the Author

Olya Ossipova

For the better part of a decade, Olya Ossipova has focused on digital transformation and innovation in healthcare. Prior to Unqork, Olya was the head of operations at a healthcare technology consulting firm, serving as general manager and consultant for clients in the healthcare, government, and nonprofit sectors.

Follow on Linkedin More Content by Olya Ossipova
Previous Video
Transformation in 21: Rapidly build your organization's digital front door with no-code
Transformation in 21: Rapidly build your organization's digital front door with no-code

Unqork's Olya Ossipova demonstrates how we empower organizations to rapidly build and effectively maintain ...

Next Flipbook
Solution Brief: Health and Human Services Case Management
Solution Brief: Health and Human Services Case Management

Streamline case management processes into a centralized digital hub to drive improved outcomes for clients,...


Read Our Blog Today!

First Name
Last Name
I Accept
By providing us with your contact information, you agree to the terms of our Privacy Policy and Terms of Service.
Error - something went wrong!