Interoperability mandates have pushed most payers to stand up FHIR APIs, but meeting the technical requirement is just the starting point. The organizations gaining a real edge are those treating FHIR as foundational enterprise infrastructure, using it to drive operational efficiency, support AI readiness and unlock long-term strategic value.
To explore where the market stands and what separates leaders from those still catching up, Becker’s Healthcare recently spoke with Mike O’Neill, CEO of MedicaSoft.
Question: How has the payer conversation around FHIR evolved recently?
Mike O’Neill: A few years ago, most payers viewed FHIR primarily as a compliance requirement driven by CMS’ Interoperability and Prior Authorization Rule. The initial focus was on meeting mandates around patient access to data — essentially standing up APIs to satisfy regulatory deadlines.
In reality, most of those implementations were tactical, standalone compliance solutions that technically exposed data but didn’t really integrate into broader operational or business strategies. The APIs existed, but organizations weren’t necessarily making effective use of the data.
More recently, payers are starting to see FHIR as more than a compliance framework. The mindset has shifted from meeting the mandate to using FHIR interoperability to aggregate and share data, and to integrate FHIR data into their operations.
For example, payers are beginning to use FHIR APIs to retrieve clinical data directly from providers instead of relying on document-based workflows. They’re also beginning to build analytics and reporting capabilities — including quality measurement and population health initiatives — directly on FHIR-based data models. That’s a significant evolution because FHIR interoperability is becoming part of the operational infrastructure rather than a separate compliance project.
That said, there are still significant gaps around workflow transformation and data quality. Many organizations can technically exchange FHIR data, but the underlying processes and data remain fragmented. And the completeness and consistency of the data is an ongoing challenge.
The organizations making the most progress are treating data interoperability as an enterprise strategy with governance, reusable platforms and operational redesign, not just an IT project.
Q: How prepared is the payer market for interoperability mandates, and what separates organizations that are ahead of the curve from those still catching up?
MO: The market is unevenly prepared. A small group of digitally mature payers is in good shape because they invested early in API infrastructure and interoperability programs. But many organizations are still catching up.
What makes this challenging is that the rule isn’t just about exposing APIs. It requires workflow redesign across the organization. The HL7 Da Vinci guides — especially CRD, DTR and PAS — provide the technology framework but implementing them requires coordination across both business and technical teams to build end-to-end workflows.
The organizations most likely to succeed are those with enterprise API strategies, strong governance and executive sponsorship. They’re also collaborating closely with providers and EHR vendors to test real-world workflows.
The organizations that will struggle are typically dealing with fragmented legacy systems, siloed ownership or overly manual authorization processes. Many are underestimating the operational change management required.
Ultimately, the differentiator will not be who can technically deploy APIs, but who can operationalize them effectively at scale.
Q: Beyond compliance, where are payers seeing measurable ROI from FHIR API investments today?
MO: FHIR-enabled clinical data exchange improves care management and utilization review workflows. When payers leverage FHIR interoperability, it improves the availability of data that helps teams make decisions more quickly with less manual effort.
Another area is quality and risk adjustment. More complete and timely clinical data supports HEDIS, stars performance and value-based care programs. Efforts like NCQA’s shift to HEDIS digital quality measures lets payers compute measures directly on FHIR data, further leveraging FHIR investments.
Although prior authorization automation is in early stages, it will reduce manual reviews, phone calls, faxes and turnaround times, and can generate meaningful operational savings.
There’s also growing strategic value around FHIR infrastructure and AI readiness. FHIR-based architectures create more accessible and higher-quality data, with traceable understanding of data provenance and governance. This level of curated healthcare data enables more powerful, cost-effective AI applications that can be achieved using raw data.
Q: As payers weigh building, buying or partnering for interoperability, what’s the right framework — and what missteps should they watch for?
MO: The most important thing is to avoid viewing data and interoperability capabilities as simply a technology procurement. Payers should focus on workflow orchestration, governance, analytics and business process optimization together with decisions on architecture and technology.
Within that framework, when considering the technology for data and data interoperability, avoid approaching it as simply a network or a database implementation. API infrastructure, FHIR servers, terminology services and other technology components are increasingly available. An end-to-end data flow that produces high-quality data must integrate these components and address patient matching, data deduplication and data quality improvements.
Once an organization views implementation in the context of maintaining high-quality data for enterprise clinical and business use, the decision to build vs. buy should become clearer. Where internal capabilities are strong and there’s differentiating value in keeping operations in-house, a build decision makes sense; otherwise, working with a platform vendor on the architecture and implementation will be most effective. And a hybrid strategy is certainly workable.
Q: How do you see the payer interoperability and FHIR landscape evolving in the next few years, and what should leaders be prioritizing right now to stay ahead?
MO: I think we’ll see a shift from FHIR being used primarily as an exchange standard to FHIR becoming a native data model inside payer organizations.
Right now, many payers still treat FHIR as an external API layer sitting on top of legacy systems. That has worked when compliance was the main objective. But as organizations look to leverage more data, they are recognizing that FHIR-native data architectures create much more flexibility for analytics, quality measurement, workflow automation, care management and AI.
One of the biggest changes will be the growth of FHIR-based operational and analytical platforms. Rather than constantly transforming data between proprietary models and FHIR, payers will begin storing and working with clinical and administrative data directly in FHIR formats — creating a more standardized, reusable foundation across the enterprise.
AI will accelerate this transition. AI applications depend on clean, structured, contextual data, and FHIR provides a more consistent framework for representing clinical information than many legacy payer data models. Organizations with FHIR-native data strategies will be far better positioned to operationalize AI at scale.
For payer leaders, the priority should be developing a long-term FHIR data strategy, not just a compliance roadmap. That means investing in scalable FHIR-native platforms, improving data quality and terminology management, and building governance models that support consistent enterprisewide use. Leaders should also be identifying high-value use cases — quality measurement, prior authorization automation, AI-enabled analytics — where native FHIR data can create measurable business value.
The organizations that stay ahead will treat FHIR as foundational infrastructure for digital operations and future innovation, not simply an API compliance requirement.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
