Beyond the regulatory checkbox: The imperative pivot to strategic compliance in payer policies

Tony Schueth
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Tony Schueth: Point-of-Care Partners, USA

Management in Healthcare: A Peer-Reviewed Journal, 2025, vol. 10, issue 1, 90-101

Abstract: As healthcare technology evolves and federal regulations mandate new health IT standards, both payer organisations and health systems are challenged with balancing compliance requirements, internal goals and feasibility. Most organisations aim for better data exchange but meet only the minimum standards due to limited resources and competing priorities. The decision to pivot to a strategic compliance plan that implements a higher standard of interoperability than is required can be a true competitive advantage. Early adopters of new technology standards are sharing proof points and success stories of organisation-wide efficiencies that demonstrate not only the benefits of proactive interoperability initiatives but also the paths that led to their implementation. This paper provides an overview of health IT policy making from agencies within the Department of Health and Human Services (HHS) to help organisations understand the separate but related impacts of final rules released by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC). A summary of the requirements of the recent CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) regarding the use of APIs (Application Programming Interfaces), particularly FHIR-based APIs, is included. And, notable changes in the amount of engagement between policy makers and the industry are summarised, such as the HL7 FHIR (Fast Healthcare Interoperability Resources) Accelerator Programme(s), participation in Connectathons and responses to CMS Requests for Information (RFIs) on proposed rules. Real-world application of FHIR-based APIs is highlighted with two case studies involving improved prior authorisation processes. Metrics provided by these health systems support the benefits of proactive compliance and how quickly infrastructure updates can provide a return on investment. An outline for a four-phase strategic compliance plan provides organisations with a guide for their own internal efforts to (a) assess interoperability readiness, (b) align decision makers and set priorities, (c) implement projects and (d) track effectiveness and optimise changes. The paper also summarises recommended tools and resources that are available to support organisations in achieving their strategic compliance planning goals and includes links to additional information that is provided. This article is also included in The Business & Management Collection which can be accessed at https://hstalks.com/business/.

Keywords: interoperability; health IT policy; data exchange; strategic compliance plans; healthcare management operations (search for similar items in EconPapers)
JEL-codes: I1 I10 (search for similar items in EconPapers)
Date: 2025
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