Part 3 of ‘Unlocking the Payer-to-Payer Shift: Compliance, Collaboration, and Competitive Edge,’ A 6-Part Blog Series
By Jim Adamson, Senior Consultant at Point-of-Care Partners and Interoperability Matters Payer-to-Payer Workgroup Lead
We’re officially less than a year away from the CMS deadline! Most payers focus on the FHIR technical requirements for CMS-0057-F. But the real challenge? The operational complexity that happens before any API call is made.
Consider this scenario: A new member enrolls Monday. By Friday, you must:
- Capture their opt-in consent for P2P exchange
- Identify their previous payers (potentially multiple)
- Locate those payers’ API endpoints
- Verify the member’s identity with previous payers
- Initiate data requests
Now multiply this across thousands of monthly enrollments, add member consent changes, concurrent coverage scenarios, and personal representative authorizations. Suddenly, P2P compliance looks very different.
The Sequoia Project’s checklist addresses these realities. Beyond technical requirements, it covers the business processes most payers haven’t considered: How do you handle consent for sensitive information? What constitutes “reasonable effort” to engage members? How do you audit compliance for CMS?
These aren’t afterthoughts—they’re compliance requirements that could make or break your January 2027 readiness.
The insight from 300+ downloads: Successful payers are thinking beyond technology to operational transformation. They’re using our checklist to identify gaps in processes, not just systems.
Take action: Get the checklist at www.sequoiaproject.org and join our workgroup discussions. We are well into our Payer-to-Payer Endpoint Directory work as well with testing opportunities expected by mid-year. Email InteropMatters@sequoiaproject.org for the next meeting details.
How is your organization addressing the operational side of P2P compliance?