The world of healthcare is extremely complex, and as such, has been divided into many, many fields and specialties. For example, for an average appointment to get a prescription, you will need a receptionist to schedule your appointment and check you in, a nurse to take your vitals and record why you’re there, a doctor to diagnose you and prescribe you medication, a billing agent to receive payment for the hospital, and a pharmacist to fill your prescription.
There are many benefits of this division, such as helping the provider be more knowledgeable in their specialty to give you better care, and streamlining your care by having a team of people work together to cover all of the areas. However, these benefits only come to be if there is communication and sharing between these specialties. A breakdown in interoperability in just one area of healthcare has a ripple effect on other areas and makes the care experience more complicated and frustrating.
To get a more up-close look at interoperability challenges in healthcare and their ripple effect, we reached out to our incredible Healthcare IT Today Community to ask — what interoperability challenges exist between clinical, billing, and payer systems, and how are they impacting revenue cycle efficiency? Their responses are below.
Ryan Christensen, VP of Product Management at AGS Health
Clinical systems often record information differently from billing or payer systems. Extracting data from a clinical note and normalizing it into a billable code is still difficult. AI has improved this, but errors in data extraction still require human eyes to fix. This creates friction that slows down automation, forcing systems to fall back on manual processing.
Additionally, these companies, at times, can lack a willingness to share. For many of these systems, just because it is possible to share data doesn’t mean it’s profitable or easy for them to do so. Some systems use proprietary formats or data tactics to keep users locked into their platform. Overcoming this requires strong partnerships and ongoing management of vendor connections. When systems don’t cooperate, staff must manually access different websites and systems to find information that could/should have been shared automatically.
Interoperability is not a “set it and forget it” solution. Every time a payer changes a policy or an EHR updates its software, the connection between them can break. It can take significant time and money to maintain these technical relationships. This constant maintenance increases the overall cost. Instead of focusing on revenue, IT and RCM teams spend their time fixing broken data pipelines or building relationships.
Jason Burke, Vice President, Revenue Cycle Solutions at Solventum
Interoperability is still one of the biggest hidden costs in the revenue cycle — because every data gap becomes human work.
When clinical documentation doesn’t translate cleanly into billing data, charge capture suffers, and denials rise. When payer requirements and prior auth rules aren’t visible in the workflow, teams get stuck reworking claims after the fact.
Solving it takes both technology and alignment: stronger integration between clinical and billing systems, better data standards, and tighter collaboration with payers. The goal is real-time transparency — so issues are resolved upstream, not discovered after the bill drops.
AI can’t fix a broken handoff. If data can’t move cleanly between clinical, billing, and payer systems, you’ll never get the full benefit — speed, accuracy, and defensibility all depend on it.
Rob Ware, SVP & General Manager at ModMed
The greatest friction in RCM remains point-solution fatigue, where practices are trapped using a patchwork of disconnected tools that require redundant manual touches. The financial impact of this inefficiency is staggering: providers currently spend enormous amounts of time and resources just trying to overturn denied claims. When data does not flow natively between clinical and billing systems, it loses its context, creating technology silos and administrative churn that stall the revenue cycle. The goal should be to ensure that clinical, billing, and payer systems share the same data points in the same context, at the same time.
Angela McCoy, Vice President, Revenue Cycle Management at AdvancedMD
The disconnect between clinical, billing, and payer systems is one of the biggest drags on RCM efficiency, putting a spotlight on the interoperability challenges affecting most practices today. Prior authorization processes are a great example of how interoperability shortcomings impact a practice’s clinical, billing, and payer systems and, ultimately, their bottom line.
Unfortunately, far too many practices still rely on manual prior authorization processes and disjointed systems that slow down daily operations, especially when it comes to billing and payer systems. The shift to API-based prior authorization workflows powered by AI-assisted technology is a real opportunity to close that gap and reduce the amount of manual work performed by providers and their admin staff.
Amy Houlihan, Managing Director, Performance Improvement – Advisory Services at Nordic
Most revenue cycle challenges come down to one thing: data doesn’t move cleanly between systems. What’s documented in the clinical record doesn’t always match what gets coded and billed—and then payer requirements add another layer of complexity. That disconnect leads to denials, rework, and delays.
Even organizations with strong internal workflows can struggle once data leaves their system and hits payer rules that vary widely. Integration is part of the fix, but it also requires consistent, trusted data across the entire process. If the data isn’t aligned among systems, the revenue cycle won’t be either.
Elevsis Delgadillo, SVP, Customer Success at KeenStack
The biggest challenge is not whether systems can connect, but whether organizations are willing to break down legacy silos. When clinical, billing, and payer systems are not aligned, it creates gaps that slow down workflows and impact efficiency. The technology exists to bring this data together, but it requires a commitment to integration across systems.
Cliff Bell, Senior Director of Value Realization at Xsolis
Health systems aren’t struggling because they lack data — they’re struggling because they lack interpretation. A dashboard can tell you that denial rates climbed last quarter; it can’t tell you why your denials climbed, with your payer mix, in your market. That gap between data and decision is where revenue cycle leaders are losing ground. The root cause is structural: the patient journey passes through siloed departments, and billing systems reduce all of that clinical complexity to a single authorization number. When revenue cycle teams can’t see cleanly into front-end clinical activity, they’re validating and adjudicating claims with incomplete context — and every information gap slows resolution and compounds risk.
Eric Makovsky, EVP, Solutions at Tendo
Interoperability remains one of the biggest structural barriers to revenue cycle efficiency. Clinical systems, billing platforms, and payer systems often operate on different architectures, data standards, and timelines. This fragmentation leads to incomplete or delayed information flow—for example, clinical documentation that doesn’t fully translate into billing data, or payer requirements that aren’t visible at the point of care. The result is manual workarounds, duplicate data entry, and increased risk of errors or denials.
Even when integrations exist, they’re often point-to-point and brittle, rather than part of a cohesive data strategy. That makes it difficult to create a unified view of the patient and their financial journey. Until interoperability improves, many organizations are compensating by building layers that normalize and connect data across systems. But the long-term opportunity lies in more seamless data exchange that enables true end-to-end visibility and coordination.
Rob Stuart, CEO at Claim.MD
One of the biggest challenges is that interoperability often stops at basic data exchange. That is not enough for the revenue cycle, which depends on data that is consistent, immediate, and reliable across clinical, billing, and payer systems. Information does not always translate cleanly between those systems, and payer requirements continue to evolve. That creates gaps that lead to delays, errors, and avoidable denials, while teams spend time reconciling data instead of moving revenue forward. Improving interoperability means going beyond connectivity to ensure the data flowing between systems can actually support clear decisions and faster payment.
Stephen Vaccaro, President at HHAeXchange
Interoperability challenges in home care often stem from disconnects between service documentation, billing workflows, and payer systems. When data has to be manually entered or re-entered across multiple platforms, misalignment is inevitable — and agencies end up spending valuable time reconciling visits, correcting claims, and tracking down missing information that should have flowed automatically between systems. That fragmentation creates inefficiencies throughout the revenue cycle that show up as higher denial rates, delayed reimbursements, and unpredictable cash flow.
Medicaid managed care plans each operate with their own authorization rules, billing formats, and documentation standards — and when provider systems aren’t built to meet those requirements in real time, small data gaps quickly become significant revenue exposures. Tighter connectivity between payer and provider systems means problems get caught earlier in the workflow, before they become denials. When visit documentation, EVV data, and authorization details are standardized and usable downstream, agencies spend less time fixing errors after the fact and more time maintaining the kind of clean, predictable revenue cycle that supports sustainable growth.
Morgan Beschle, Vice President of Kyruus Product at RevSpring
The most urgent interoperability challenge in healthcare today isn’t between billing systems, it’s between health systems and where consumers are actually going for answers. A patient is opening your website to start their search less and less. They’re typing into ChatGPT, asking Gemini, or discussing with a voice agent that answers the phone. If your provider data, availability, insurance networks carried, and pricing aren’t structured and accessible where those AI agents are operating, you’re losing the care relationship entirely. The revenue cycle starts with access. If access is broken at the discovery layer, no amount of back-end billing optimization fixes it.
So many interesting points to consider here! Huge thank you to everyone who took the time out of their day to submit a quote to us! And thank you to all of you for taking the time out of your day to read this article! We could not do this without all of your support.
What interoperability challenges do you think exist between clinical, billing, and payer systems? How do you think they are impacting revenue cycle efficiency? Let us know over on social media, we’d love to hear from all of you!
The following is a guest article by Dylan Abrams, Lead Clinical Psychologist at 
About Dr. Shazia Fathima