The Elephant in the Room: Industry Gaps That Could Derail P2P Compliance

Part 4 of ‘Unlocking the Payer-to-Payer Shift: Compliance, Collaboration, and Competitive Edge,’ A 5-Part Blog Series

By Jim Adamson, Senior Consultant at Point-of-Care Partners and Interoperability Matters Payer-to-Payer Workgroup Lead

Here’s what keeps me up at night about CMS-0057-F: The regulation mandates payer-to-payer exchange, but critical infrastructure pieces remain undefined.

Gap #1: Payer Endpoint Discovery How do you find another payer’s API endpoint? There’s no national directory. No phone book. Each payer must somehow discover and maintain connections with potentially hundreds of other payers.

Gap #2: Standards Adoption Uncertainty CMS “strongly recommends” Da Vinci PDex IG, but doesn’t mandate it. What happens when Payer A uses PDex, Payer B uses a custom approach, and Payer C isn’t ready at all?

Gap #3: Error Communication Protocols When exchanges fail—and they will—how do payers communicate? What’s the escalation process? Who resolves data quality disputes?

These aren’t hypotheticals. Our Workgroup discussions reveal that every payer is grappling with these same questions. The organizations acknowledging these gaps now are the ones developing contingency strategies.

The Sequoia Project approach: Our checklist helps payers identify these blind spots and develop practical workarounds. We’re fostering industry collaboration to address what individual payers can’t solve alone.

The encouraging news: With 400+ checklist downloads, there’s clear industry momentum to solve these challenges collectively.

Get involved: Download the checklist. Join our collaborative effort to fill these industry gaps. Contact interopmatters@sequoiaproject.org for more information on how to get involved.

Which industry gap concerns you most? Let’s discuss solutions.