Five Insights from the WEDI Summer Forum
By: Nancy Spector, WEDI Senior Director, Federal Affairs
WEDI’s 2026 Summer Forum in Chicago was a big success with its focus on the CMS Interoperability and Prior Authorization regulations (0057-F and 0062-P). Attendees were offered a “whirlwind” of valuable information from expert speakers (ending day two on the heels of tornado warning sirens in downtown Chicago). Those in the Windy City and on zoom took the knowledge, expertise, and experiences they learned about implementing these challenging CMS regulations back to their organizations. If you missed the forum, here are five important insights from the event.
1. Provider and consumer education on APIs must be prioritized.
The CMS-0057-F and 0062-P regulations are the biggest push to date by CMS to require the use of application programming interfaces (APIs) for the exchange of health information to deliver on a more efficient and patient-focused health care system. The question on the minds of people at the WEDI Summer Forum was, “Will the APIs be used?” Lorraine Doo, former CMS senior policy advisor, spoke about the industry’s work for over 20 years to transform health care data exchange and how this work requires strong collaboration between standards development organizations and industry users to go beyond just technology and address operations and data flow. Patients and consumers’ use of this technology is critical to achieving the usability of health data. They must be educated on the patient access and payer-to-payer APIs, so they are empowered to access their data, engage with health apps, and use them to allow the sharing of their data appropriately to support their care. The need for provider education on the APIs was also raised during the forum’s interactive exercise, led by Steven Berkow from InterSystems. The exercise challenged attendees, working in cross-industry stakeholder teams, to identify the capabilities, investments, and potential barriers needed for APIs to truly become transformative solutions for health data exchange between payers and providers.
2. The success of electronic prior authorization hinges on digitizing prior authorization policies.
Michael Lunzer from Itiliti Health, and co-chair of the WEDI Prior Authorization Subworkgroup, highlighted the challenges and need for turning current prior authorization policies into structured, clinically governed automated policies for the API environment. One issue is maintaining alignment between the human-readable medical policy and the corresponding Fasth Healthcare Interoperability Resources® (FHIR®) questionnaire, particularly when policies are converted into questionnaires through manual or automated processes. Effective digitization also requires linking procedure codes to the appropriate policy and questionnaire sections and translating subjective clinical criteria into objective, clearly answerable questions. In addition, health plans need to retain completed questionnaires and supporting documentation as accessible historical records for utilization management and decision-making. Success of digitizing these policies lies in the ability to transform the foundation of current manual processes into an automated, more effective, and end-to-end business process.
3. Endpoint discovery is a challenge that must be addressed.
The challenges associated with endpoint discovery have not gotten enough attention to date. The panel with Donald Rucker, MD, and Jeremy Yoon from 1upHealth, Karuna Relwani from Blue Cross Blue Shield Association, and Rana Chaudhuri from CareFirst BCBS dug into this issue. Many anticipate that payers and providers will face difficulties identifying the correct endpoints, determining which systems support specific transactions or APIs, and maintaining accurate information as connectivity requirements evolve. The panelists focused on the need for industry collaboration, consistent standards, reliable and up-to-date endpoint information, and capabilities that make endpoint discovery simple, scalable, and operationally useful. Addressing these challenges will lead to reduced administrative burden, more seamless exchange of information, and better automation across the health care ecosystem. Success will mean that providers and payers can more easily identify where and how to connect.
4. The opportunities for APIs in health data exchange extend far beyond 0057-F and 0062-P.
While presenters talked primarily about the electronic prior authorization and access APIs, the opportunities that APIs offer beyond the regulations were also highlighted. APIs were discussed as having the potential to improve the exchange of health care data by creating a more connected, automated, and scalable health care ecosystem. As Cotiviti’s Kevin Day emphasized in his session, these innovative solutions will enable real-time or near-real-time access to information across payers, providers, patients, and other stakeholders, reducing reliance on manual processes, proprietary connections, and point-to-point data exchange. Broader adoption of API technology can support a variety of use cases, such as care coordination, population health management, clinical information exchange, and many others. Expanding API adoption beyond the specific regulatory requirements can help establish a more interoperable foundation for health care, leading to better outcomes and experience for providers, payers, and patients.
5. The benefits of “real world” testing between trading partners are real and cannot be overestimated.
Throughout the Forum, the benefits of real-world testing were repeated again and again by vendors, clearinghouses, payers, and providers. While organizations may have their foundational components ready for the compliance date, the exact functionality around sending and receiving data, deploying newly automated processes, digitization of policies, and many other more detailed changes will not be known until the end-to-end data flow and processing begins. There are many challenges with external testing, from finding organizations to test with, to having the time and resources to do it. Speakers, including Tim Bennett from Drummond, emphasized that problems from large scale system changes, like 0057-F and 0062-P, will not be known until real-world data exchange happens. External testing is best conducted prior to the compliance date. Organizations testing during production, when the stakes of information flow, data accuracy, and overall functionality are most critical, run the risk of encountered challenges that could impact business operations.
If you missed the WEDI Summer Forum and these topics are important to you, do not miss WEDI’s National Conference coming up in Washington, DC on October 26 – 29. View the registration and agenda, and do not miss the early bird discount.