Skip to main content

How interoperability drives business value

Katie Devlin, DHSc, MS, CPHIMS and Adam Gilbert

The exchange of digital data in healthcare presents a significant opportunity for payers to minimize waste, reduce inefficiencies, and enhance the timeliness and quality of information used to support care decisions. By fostering interoperability among healthcare stakeholders, organizations can unlock the full potential of structured data, strengthening their ability to drive informed decisions and enhance organizational intelligence. This, in turn, lays the groundwork for improved risk adjustment and better quality outcomes. However, the benefits of interoperability come with challenges, including the need for substantial investments, specialized expertise, and dedicated resources.

In this eBook, we’ll offer insight into regulatory trends related to interoperability, explain how payers can leverage interoperability to improve risk adjustment and quality outcomes, and offer key recommendations for organizations to incorporate into their interoperability strategies for 2025 and beyond.

Regulatory updates and emerging opportunities

In recent years, regulatory changes have focused on improving interoperability by broadening access to structured clinical data and prioritizing seamless data exchange. The Trusted Exchange Framework and Common Agreement (TEFCA) has emerged as a pivotal initiative, paving the way for efficient, nationwide data exchange.

The initial version of the Common Agreement emphasized use cases such as treatment and individual access. However, the release of TEFCA version 2.0 in 2024 expanded its scope, introducing support for FHIR-based exchanges and broadening exchange purposes to include healthcare operations (HCO) for use cases such as quality reporting and patient stratification. By participating in a Qualified Health Information Network (QHIN), payers and their healthcare analytics partners can streamline digital data exchange, gaining access to high-quality data through a unified source with consistent formatting.

The CMS Interoperability and Prior Authorization Final Rule, which federally funded payers must comply with by January 1, 2027, has helped health plan organizations set clear timelines and deadlines for their interoperability projects as they seek to meet the requirements of implementing FHIR-based APIs to enhance interoperability and streamline prior authorization. 

By participating in a QHIN, payers and their healthcare analytics partners can streamline digital data exchange, gaining access to high-quality data through a unified source with consistent formatting.

Looking at quality programs, the National Committee for Quality Assurance (NCQA) aims to transition to all-digital measures for HEDIS reporting by 2030, leveraging the FHIR standard to reduce potential errors as the industry moves away from manual processes like faxing and mailing. NCQA has launched a Bulk FHIR API Quality Coalition focused on testing the content of clinical data sourced from FHIR APIs. The coalition includes cohorts of payers, Data Aggregator Validation (DAV)-certified data partners, and vendor partners who are testing this data against HEDIS-specific FHIR implementation guides. Upon data collection, the coalition will evaluate how bulk FHIR APIs perform and assess the accuracy of the data received.

As regulations continue to evolve, healthcare organizations must closely monitor implementation progress, understand impact on specific markets and use cases, and adjust their operations. 

Business impact

Interoperability primarily benefits healthcare payers by driving impact across three key areas: data acquisition, data standardization, and care delivery. 

Today, clinical data is retrieved in various formats from disparate sources, including electronic health records (EHRs), lab results, and claims data. Interoperability enhances data acquisition by reducing retrieval time, maximizing the volume of records obtained, minimizing provider abrasion, and streamlining administrative processes. Efficient data acquisition facilitates seamless exchange and consistent formatting, reducing manual errors and inconsistencies.

Greater data standardization enables payers to leverage uniform formats across channels and sources, providing timely, high-quality data. This practice fosters improved collaboration among stakeholders and supports the implementation of advanced analytics and AI-driven programs to generate deeper insights.

Access to real-time, comprehensive data empowers health plans to elevate their risk adjustment and quality program outcomes. Additionally, it provides a holistic view of members, enabling more effective population health strategies. With more precise risk assessments and tailored care plans for high-risk individuals, healthcare organizations can improve member care while ensuring appropriate reimbursement through optimized risk adjustment programs.

Access to real-time, comprehensive data empowers health plans to elevate their risk adjustment and quality program outcomes.

Key recommendations

Based on Cotiviti’s experience with more than 200 payer clients, here are recommendations for achieving a scalable interoperability program: 

Set up an internal taskforce, involving leaders across numerous areas. Gain insight from IT, legal, and clinical leaders to determine interoperability requirements and their impact on current operations. Monitor regulatory trends and identify their impact and requirements for your specific use cases. External partners with dedicated expertise can help accelerate innovation and support plans to meet their deadlines and goals. 

Join external working groups of peers and experts in testing and learning new digital requirements. As an example, the HL7 Da Vinci Project is a private sector initiative focused on accelerating FHIR adoption. In response to recent regulatory changes affecting payers, this coalition established a workgroup to validate and test payer-driven use cases, called the Da Vinci Trebuchet Pilot. The Trebuchet Pilot includes payers, providers, and technology vendors testing scenarios such as prior authorization and TEFCA exchange to help ensure the technical requirements make sense for real-world scenarios.

Implement scalable technology infrastructure to enable integration with different data sources. Establishing a diversified range of connections and network options such as QHINs, health information exchanges, and health systems, along with implementing FHIR-based APIs, is critical for success. Partnering with high-quality experts can help address specific market needs, identify opportunities, and design effective strategies, all while helping achieve compliance with regulatory requirements.

Establishing a diversified range of connections and network options such as QHINs, health information exchanges, and health systems, along with implementing FHIR-based APIs, is critical for success.

Establish strong data management processes. Adopting industry standards like HL7 and FHIR help streamline the retrieval and exchange of accurate data. Currently, healthcare organizations are using different standards (e.g., FHIR, C-CDA), or even different versions of the same standard. This means that it is essential to have a robust data mapping and quality management strategy. Initiatives must focus not only on establishing the right digital network connections but also on fostering effective collaboration between payers and data partners. Timely access to data is critical for identifying issues and continuously optimizing quality. Regular data quality audits, combined with close coordination with data partners, are essential to ensure data accuracy and address areas for improvement.

How Cotiviti drives value through interoperability

Cotiviti supports health plan leadership in their interoperability transformation journey through:

  • Regulatory guidance: We help clients understand regulatory requirements and identify the impact on their specific programs and use cases. 
  • Scalable technology infrastructure: We help clients build a strong digital data strategy, powered by our leading digital network, multiple integration capabilities, and dedicated technology, such as FHIR APIs and provider portal, to boost provider engagement.
  • Partnership and data management: We support payers, providers, and data partners in their interoperability journey, addressing concerns about privacy, provider abrasion, and workflows. From strategy design to regular data quality audits, our support drives improved outcomes and creates value for all parties involved.

Interoperability is transforming healthcare data management by advancing data acquisition, standardization, and integration. As regulatory changes reshape the industry, healthcare organizations must adapt and innovate to maintain compliance and enhance patient care. Embracing interoperability unlocks new opportunities for greater efficiency, improved accuracy, and better patient outcomes.

Start the conversation with Cotiviti to learn more about how we can help you advance your interoperability priorities.

Schedule a conversation

About the authors

Katie Devlin, DHSc, MS, CPHIMS

Katie Devlin, DHSc, MS, CPHIMS
Vice President, Interoperability

Katie is responsible for creating an enterprise-wide health data exchange strategy to address our clients’ unique business needs while reducing provider abrasion, maintaining regulatory compliance, and optimizing value. She oversees all initiatives related to digital health data acquisition, ingestion, storage, and normalization, including the expansion of Cotiviti’s electronic health data networks and strategic partnerships. Drawing on her extensive informatics and health information exchange experience, Katie is an advocate for ensuring health information is delivered in a way that enhances the member, provider, and payer experience. 

Adam Gilbert
Director, Interoperability Operations and Partnerships

Adam works collaboratively with payers, providers, and vendors to increase the use of clinical data exchange. With over 20 years of experience in healthcare operations and consulting, Adam is committed to enhancing the healthcare landscape through effective interoperability strategies and operational excellence. Prior to joining Cotiviti, he held senior management roles at Change Healthcare and McKesson.