CMS-9115-F: A Misunderstood Interoperability Foundation

CMS-9115-F, the Interoperability and Patient Access Final Rule, might be one of the most misunderstood regulations in healthcare technology history. It is often dismissed as a burdensome mandate that offered payers little to no return on their investment—but this perception fails to consider the regulation’s full intent.

CMS-9115-F was never designed to deliver financial returns; rather, its purpose was to establish the technical and operational foundation that would support a modernized digital infrastructure, improve data accessibility, and enable innovation.

The Intent Behind CMS-9115-F

CMS made their intent for 9115-F clear:

This final rule focused on driving interoperability and patient access to health information by liberating patient data using CMS authority to regulate Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program (CHIP), and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).

This statement underscores CMS’ commitment to empowering patients with access to their own health data and improving the flow of information across the healthcare ecosystem. The mandate also emphasized the use of standardized Application Programming Interfaces (APIs) to facilitate electronic data exchange.

By requiring APIs built on the Fast Healthcare Interoperability Resources (FHIR®) standard, CMS-9115-F established a consistent framework for secure, real-time data exchange that was designed to replace the siloed data systems that hinder stakeholder collaboration and care coordination.

Standardized communication is essential for building a responsive, data-driven healthcare platform—but healthcare organizations have historically struggled to agree on shared technological standards. Without CMS-9115-F, it’s unlikely healthcare organizations would have agreed on a single unified data exchange standard on their own.

ROI: Misconceptions and Opportunities

While CMS never positioned 9115-F as a revenue-generating initiative, the potential for financial benefit is significant. Possibilities include:

• Reducing operational costs by automating data exchange and reducing manual processes (sending faxes, phone calls, paper-based workflows, etc.)
• Streamlining prior authorizations to lower administrative overhead, accelerate decision-making, and improve provider satisfaction
• Enhance value-based care performance by enabling timely access to actionable patient data that reduces avoidable hospitalizations and improves outcomes
• Facilitating data-driven partnerships through secure, scalable access to claims data, helping to reduce medical costs through earlier interventions, lower administrative overhead, and enable shared savings in value-based care models

As these benefits demonstrate, CMS-9115-F and CMS-0057-F are more than regulatory obligations—they are strategic investments in infrastructure that can improve payer performance and profitability while advancing interoperability for the entire healthcare system.

Unlocking the Value of FHIR Investments

CMS-0057-F builds on the FHIR-based architecture of CMS-9115-F by requiring payers to support additional use cases, such as the prior authorization and payer-to-payer APIs. These capabilities depend on the secure, standardized data environment established by CMS-9115-F—in other words, without that groundwork, fulfilling the advanced API requirements of CMS-0057-F would be virtually impossible.

Investing in CMS-9115-F requirements gave payers the ability to more easily adapt to both CMS-0057-F and future mandates. This, in turn, allows payers to benefit from:

• Seamless data exchange across systems to improve care coordination, reduce duplication, and minimize administrative burden, leading to lower medical and operational costs
• Advanced analytics that help payers identify trends, predict outcomes, and make more informed financial decisions that support better risk management and cost forecasting
• Automations and efficiencies that reduce manual work, lower costs, and enhance provider workflows and member experiences to drive down administrative spend and improve retention
• Payers who viewed CMS-9115-F not as a compliance checkbox but as an opportunity to strategically modernize their infrastructure are already reaping the benefits.

The Cost of Minimal Compliance

Some payers complied with the letter of CMS-9115-F rather than the spirit, investing as little as possible to achieve the minimum functionality required by the ruling. While this approach may have reduced short-term costs, their fragmented systems and siloed data will continue to limit scalability and make it harder to implement new capabilities.

As data access becomes increasingly critical for care coordination, payers that delay modernization based on short-term financial decisions risk falling behind their more forward-looking competitors.

Interoperability as a Strategic Advantage

The healthcare industry is at a critical juncture. Interoperability is no longer a “nice-to-have,” it is a strategic imperative. Payers that invest in robust, scalable, and secure interoperability systems position themselves for long-term success.

CMS-9115-F may not have delivered the ROI some payers expected, but immediate ROI was never the goal. The objective was to create a universal framework that could support more advanced interoperability initiatives and ultimately enable a more connected, efficient, and patient-centered healthcare system.