When it comes to regulation, most people ask: “What’s the fastest way to meet CMS interoperability requirements?”
That’s the wrong question.
The right question is: “How do we turn CMS deadlines into a business case to finally fix what’s been broken for years?”
Here’s the reality: The regulatory landscape isn’t slowing down and it isn’t getting any easier. CMS interoperability mandates, prior authorization transparency, and enhanced HIPAA protections for electronic health information—these aren’t isolated compliance tasks. They’re converging into one unavoidable truth:
- Payers who treat these as checkboxes will spend millions just to stay compliant.
- Payers who treat them as catalysts for transformation will improve member outcomes, reduce costs, and boost Star ratings—all while meeting the same deadlines.
I've spent enough time in this industry to recognize the pattern. Compliance pressure hits. IT scrambles to build a solution. The mandate gets met. Everyone exhales. And then nothing changes on Day 2.
That's the compliance trap. And it's expensive.
What Checkbox Thinking Actually Costs
Let's be honest about what happens when organizations focus on minimum requirements without strategic planning. You end up with isolated systems that don't talk to each other, and you add another one-off solution to your growing stack of solutions. You solve for prior auth transparency but miss the opportunity to reduce appeals. You implement interoperability standards but still have members calling three different numbers to understand their care journey.
The claims process really should be quite simple. Instead, we've made it so complicated that it incurs massive costs. We've built silos, added layers, created friction - and then we wonder why appeals are up, providers are frustrated, and Star ratings aren't as good as we think they should be.
But here's what I'm seeing from the payers who get it: They're asking a fundamentally different question. Not "Are we compliant?" but "Are we making healthcare more accessible?"
The Opportunity Smart Payers Are Seizing
I had a conversation recently with leaders from Cigna’s Evernorth subsidiary and Highmark Health’s enGen subsidiary, and they're approaching this shift in a way that should make every CFO and COO pay attention.
GK from Evernorth said something that stuck with me: "If you're just doing the basics, it's going to catch up with you." He's not talking about regulatory penalties. He's talking about the competitive gap that opens when your organization treats mandates reactively while others use them to anticipate change and break down silos to eliminate friction for members and providers.
Matt from enGen framed it differently: "What does the end state look like? Clinicians and payers should readily have the information they need to care for members. Systems talk to each other so members see seamless care, not silos."
That's the shift. A change in mindset in which compliance becomes the lever for three critical improvements:
First, you automate and streamline workflows that have been drowning your operations team. Prior authorization, claims processing, appeals management - these aren't separate problems. They're symptoms of fragmented systems. Use AI to orchestrate an experience to reduce administrative burden. Build workflows that decrease the time from request to decision. Smart automation doesn't just meet compliance requirements; it’s reusable and scales across multiple processes to improve efficiency everywhere.
Second, you finally break down the silos that fragment member experience. Interoperability isn't just about meeting CMS timelines. It's about creating a holistic view of members so you can deliver proactive care instead of reactive interventions. Connect your systems so that data flows where it needs to go before a claim even starts. That's how you move from value-based care aspiration to reality.
Third, you embed security and transparency as your competitive advantage. HIPAA enhancements demand stronger data privacy protections. Prior auth mandates require transparency. These requirements aren't opposing forces - they're the foundation for trust. When you build systems that protect data while making care journeys visible to members and providers, you're not just compliant, you're earning the trust that drives higher satisfaction scores and better Star ratings.
The Questions You Should Be Asking Right Now
As your organization is planning for upcoming CMS mandates, here's what should be on your roadmap:
Do you have an interoperability plan aligned with CMS timelines, or are you waiting to see what happens? Are your prior authorization workflows automated, or are you still manually processing requests that could be resolved in minutes? Have you implemented claims accuracy and speed improvements, or are appeals still eating up operational resources?
Beyond the immediate mandates, are you building an AI strategy for predictive care planning? Do your security and privacy controls meet HIPAA standards while enabling the data transparency members expect? Have you defined KPIs tied to Star ratings and member experience, not just compliance metrics?
And here's the most important question: Do you have a long-term transformation plan in place to anticipate future mandates and adapt proactively, or are you planning to do this scramble again in two years?
Start With Quick Wins, Build Toward Transformation
The good news? You don't have to solve everything at once. The organizations I'm seeing thrive are starting with immediate, visible improvements that contribute to their strategic plan to build toward systemic improvement.
Automate prior authorization notifications so members and providers get real-time updates instead of waiting days for status changes. Implement real-time claims validation to catch errors before they become appeals. These quick wins reduce friction immediately while you build the larger transformation roadmap.
Then tackle the bigger opportunities: Map your workflows for prior authorization, claims processing, and member experience to see where silos are costing you time and money. Assess your AI readiness - not just for compliance, but for predictive care planning that moves you toward genuine, high-quality, value-based care outcomes. Build your compliance-to-transformation roadmap with clear milestones, stakeholder alignment, and KPIs that matter.
The Triangle That's Broken - And How to Fix It
"The triangle is broken. Members, providers, payers - how does this work together? How do we reach consistent changes across all three?"
That's what transformation looks like. Not isolated compliance projects. Not checkboxes. Connected systems that serve members, reduce provider friction, and improve operational efficiency for payers - all at the same time.
CMS deadlines aren't the finish line. They're the starting gun.
Ready to see what this looks like for your organization?
Build your own Blueprint to map your path from compliance to transformation.