We have come a long way in improving the world of healthcare – largely thanks to improving interoperability and data standardization. However, the work is not yet complete. Every day, we continue to push forward, think, and try out new things. This push can either lead to a new solution that further improves healthcare, or it can lead to new challenges or further exploit old challenges. So what does this look like in terms of payer-provider integration? What challenges still linger, and what is being done about them?
We reached out to our brilliant Healthcare IT Today Community about this, and asked — what interoperability or data standardization challenges continue to hinder payer-provider integration, and how are they being addressed? Below are their responses.
Robert Connely, Global Industry Market Leader, Healthcare at Pega
While data standardization and interoperability are critical, the underlying problems often have more to do with data sharing rights and consent to access the data beyond integration. This is where programs like Value-Based Care offer unique opportunities to enable informed consented relationships between patients and providers to engage and share data. This is a big part of care management systems today. They are continuing to evolve and becoming core capabilities with modern orchestration platforms.
Ben Maisono, SVP Strategy at Tendo
Despite progress, interoperability challenges remain significant—particularly around data completeness, standardization, and workflow integration. A major issue is that clinical data and claims data are often structured differently and captured for different purposes. Even when organizations exchange data via FHIR APIs or HL7 feeds, the underlying variation in coding practices, documentation quality, and system configurations can limit usability. Another ongoing challenge is patient matching across systems, especially when data is coming from multiple provider networks or community-based organizations.
To address these barriers, many organizations are investing in: data normalization and governance frameworks, industry-wide adoption of FHIR-based exchange, trusted health information networks and exchanges, and improved consent management and identity resolution tools. The focus is shifting from simply “sharing data” to ensuring the data is meaningful and actionable at the point of care.
David B. Snow Jr., Founder and Head of Value-Based Care at Cedar Gate Technologies, an IQVIA business
Data interoperability is an ongoing challenge in healthcare. In a competitive industry where everyone wants to shield their own data—while also adhering to strict privacy and data protection laws—the data sharing barriers are extensive. Federal initiatives like FHIR and HL7 are aimed at making it easier to exchange data across disparate systems, but like many healthcare initiatives, government mandates won’t be enough. Private industry must step in and develop enterprise data capabilities that can bring it all together effectively.
It is a monumental task. Effective data sharing and interoperability requires tools to pull from hundreds of data sources into one single place, as well as the ability to cleanse, enrich, and normalize the information into a single, usable format. The good news is that we now have the capabilities to do it at scale—resulting in accurate, homogenized data that both payers and providers can trust to implement complex VBC and risk-based models. As healthcare IT advances, the process of creating effective, integrated data systems will become even faster and more accurate, and the ability to scale up to handle extensive datasets in healthcare will increase.
Maxim Abramsky, Vice President of Product Management at Cotiviti
Today, payer-provider integration is hindered by basic misalignments. Direct API-to-API communication between many payer systems and provider EMRs is limited, and when these systems do talk to each other, the underlying data models and workflows aren’t always aligned. That means what should be “standard” exchanges in theory can behave very differently in reality. Intermediaries (clearinghouses, proprietary networks, and vendor-specific gateways) often introduce extra translation layers, fees, and operational constraints, which can increase implementation complexity and reduce end-to-end transparency.
These issues are being addressed through broader adoption of HL7 FHIR + SMART-on-FHIR, payer/plan-facing interoperability gateways, and evolving regulatory initiatives (e.g., CMS Interoperability and Prior Authorization rules). These approaches encourage more real-time, standards-based exchange and reduce reliance on manual processes like fax.
Overall, the industry continues to move closer to standardizing both EMR capabilities and payer interoperability layers. As technology advances, perspectives shift, and the results of streamlining begin to speak for themselves. As organizations increasingly evaluate and adopt standardized, API-driven exchange, there is potential for improved adoption and reduced administrative burden across the industry.
Paul L Wilder, Executive Director at CommonWell Health Alliance
Trust in interoperability is still the biggest barrier to seamless payer-provider integration. Other barriers include confusion around standards and what to use where, from CMS’s FHIR-based APIs to HEDIS and other quality programs that require document-based exchanges. Payers who want to be ahead of the curve should take action now, testing and scaling when and where it most benefits their needs. Getting involved earlier also helps them more strongly influence future roadmap development. Once trust is earned, interoperability will serve as the essential platform that brings together not only payers and providers, but also patients and public health initiatives.
Marie Mitri, Director of Business Development at Navina
While standards such as FHIR have significantly improved system connectivity, challenges remain around data completeness, timeliness, and reliability. Payer data often reflects claims-based information with inherent lag, while provider documentation can vary in depth and structure, which limits how actionable shared data is at the point of care. Addressing these gaps requires reconciling discrepancies between clinical and claims data and ensuring information is presented in a way clinicians trust and can act on. Organizations making sustained progress are those that focus not just on exchanging data, but on improving its accuracy and usability within everyday clinical workflows.
Ashley Basile, Chief Product Officer at Availity
Despite progress with interoperable data standards like FHIR, payer-provider integration is still challenged by inconsistent data quality and varying implementation standards. Even when standards like FHIR are in place, differences in implementation and incomplete clinical context can limit the real-world usability of data. The industry is addressing this by focusing less on point-to-point integrations and more on shared networks, normalization and translation layers that sit between source systems and end users, and trust frameworks that scale. Success depends on translating standards into usable, action-oriented data that fits naturally into payer and provider operations and shifting from simply “moving data” to making data trustworthy, usable, and actionable across the ecosystem.
Denis Whelan, CEO at Documo
One of the biggest barriers to stronger payer-provider integration isn’t the lack of APIs or standards – it’s the reality that so much critical information still arrives as unstructured documents. Prior authorizations, clinical notes, and supporting records often come in different formats, across different channels, with inconsistent fields and varying levels of completeness. Even in highly digital environments, that variability creates friction.
Interoperability works best when data is already structured. But when information enters the system as a PDF or scanned document, someone has to interpret and standardize it before it can move cleanly between systems. That manual orchestration between systems is where delays and errors often begin.
Intelligent Document Processing and automated document workflows help close that gap by turning unstructured content into structured, validated data at intake, then orchestrating the flow of that content across systems. By standardizing information as it enters the workflow, organizations strengthen data integrity and create a more reliable foundation for meaningful integration between payers and providers.
Hamid Tabatabaie, Founder and CEO at CodaMetrix
Interoperability isn’t failing because we lack APIs. We already have standards to exchange data. The real issue is upstream. Every provider configures their EHR differently — templates, workflows, mappings, definitions of quality. Clinical documentation is narrative and contextual. Revenue cycle data is abstracted and financially optimized. By the time data flows through “standardized” interfaces, it’s structurally clean — but semantically misaligned. We’re exchanging data, not shared meaning. The future isn’t just better pipes. It’s objective frameworks that normalize variation at the source and translate clinical nuance into consistent, high-integrity coded data. When definitions align, interoperability becomes shared understanding. And that’s when integration actually works.
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. While the technology exists to unify clinical, claims, lab, and social determinants data, integration requires a commitment to shared standards and coordinated infrastructure across payer and provider environments.
Monte Sandler, Chief Operating Officer at WebPT
The transaction formats and EDI structures have not meaningfully evolved in decades, and they were not designed for today’s level of automation. The bigger challenge is the complexity layered on top, including multiple payers, unique rules, benefit designs, and coding requirements. Rather than waiting for new standards, providers and health IT organizations are using AI to interpret and operationalize the existing data more effectively. The advancement is in how the data is processed, not in the data itself.
Joanna Engelhardt, VP of Product Management at Health Gorilla
Despite progress, payer–provider integration is still slowed by inconsistent data standards, including variable data quality and fragmented governance. Organizations addressing this successfully are prioritizing shared standards and disciplined interoperability processes. Stable, trusted exchange is so much more than a technical requirement. It’s foundational to care coordination, payment accuracy, and patient trust.
Hilla Fogel, Ph.D, Founder and CTO at QuantalX Neuroscience
Interoperability between payers and providers continues to face several challenges. While standards such as FHIR have gained traction, adoption remains inconsistent, and implementation varies across systems. Even when data is successfully exchanged, semantic differences in coding, terminology, and documentation can limit true interoperability and usability. Many organizations still rely on legacy, siloed infrastructure that was not designed for modern, API-driven integration. Data quality issues, including incomplete, inconsistent, or unstructured information, further reduce reliability for analytics and quality reporting.
Additionally, privacy regulations and evolving consent requirements introduce operational complexity. Addressing these challenges requires more than technical upgrades; it demands stronger governance, standardized implementation practices, and greater alignment across the payer–provider ecosystem.
So many great insights 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 or data standardization challenges do you think continue to hinder payer-provider integration? How do you think they are being addressed? Let us know over on social media, we’d love to hear from all of you!
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