Beyond Compliance: How Interoperability Can Fix Billing and Rebuild Trust in Healthcare

 

 

“You can’t improve what you can’t measure—and you can’t measure what you can’t connect.”

— Dr. Eric Topol (via a commentary published this week in Health IT literature)

 

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The Hidden Cost of “Compliant” But Disconnected Healthcare Systems

Imagine you're a doctor running late to your next patient. You pull up the EHR—and it's fragmented. Lab results stuck in a portal. Pharmacy claim invisible to the billing system. An unpaid claim lodged because payer and provider systems don’t talk.

This is reality for too many. It’s not that healthcare systems don’t know how to exchange data—they've often checked the compliance box with standards like FHIR. But compliance isn’t connection. It's like having a passport but never boarding the plane—even less useful for the return trip.

This isn’t theoretical. A recent analysis reveals many systems are technically “compliant”, yet functionally fragmented, crippling real-time billing, care coordination, and patient engagement. PlektonLabs

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Why This Matters Now (Even for Billing Teams)

Three hot-off-the-press developments:

1. CMS’s new “digital health ecosystem” initiative pushes voluntary interoperability frameworks for patients, providers, and health IT vendors—with more than 60 organizations pledging to meet objectives by Q1 2026. American Hospital Association
2. The HL7 FHIR Connectathon, held July 15–17, 2025, spotlighted FHIR innovations and real-world testing that directly inform payer-provider billing workflows. CMS
3. The PACIO Project’s latest: in July 2025, FHIR implementation guides for transitions of care and standardized medication profiles were successfully tested—critical for billing accuracy in post-acute and chronic care settings. pacioproject.org

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Expert Voices: What’s Working, What’s Broken, and What’s Next

1. Dr. Aisha Reed, CMIO at a major health system

“FHIR finally gives us a common language across EHRs, payers, and apps—but only when it’s actively implemented across workflows, not just stuck in compliance documents.”

2. Mark Nguyen, Healthcare Ops Consultant

“I've seen billing staff waste hours undoing mismatches caused by siloed systems. The difference between syntax and semantics becomes painfully clear when you can't match records between provider and payer.”

3. Sarah López, Post-Acute Care Director

“PACIO’s new FHIR medication profile testing is a breakthrough. It means medication data can travel cleanly from hospital to skilled nursing facility—and billing follows the patient, not the paperwork.”

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Five Tactical Tips to Move from Compliant to Connected

1. Map Your Data Pathways
   Audit your systems: where is data blocked, duplicated, or lost? Fix one broken link each quarter—e.g., lab-to-billing match or payer eligibility check.
2. Use Real FHIR APIs, Not Just Mock-ups
   Participate in events like CMS Connectathons. Prototype integrations—not theoretical exercises, but interoperable billing requests flowing through real APIs.
3. Build Governance, Not Just Tech
   Open data schemas and API policies only work if teams know whom to call when data fails. Assign responsible owners for each interface and reconciliation workflow.
4. Embrace Vendor-Neutral Architecture
   Don’t lock your systems to EHR or payer API ecosystems. FHIR enables flexible, platform-agnostic integrations. This keeps billing agile and data portable.
5. Track Outcomes, Not Metrics
   Measure error rate before vs. after live data exchange, claim rejection reduction, or billing turnaround time—don’t just watch raw API hits.

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Relatable Failure (So You Can Learn Faster)

Once, a regional health center launched FHIR-based data sharing with a payer network—and proudly celebrated “API calls hitting production.” But billing errors skyrocketed when test environments mismatched real-world payer codes. Lesson: Pass live-like test data, not sanitized ideal cases.

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Myth-Buster: Interoperability Myths—Busted

Myth	Truth
“Interoperability is just an IT project.”	It’s a clinical, operational, regulatory, and financial transformation. Requires governance, training, culture.
“Once compliant, always connected.”	Compliance with standards (e.g. FHIR) doesn’t guarantee ongoing, accurate data exchange. Connection must be maintained. PlektonLabs
“FHIR solves everything.”	It’s a powerful tool—but only as good as its implementations, mappings, and workflows.

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FAQs: Quick Answers Busy Professionals Need

Q1: What specific benefits does FHIR deliver for billing?

• Enables real-time eligibility checks, accurate coding, integrated claims submission. Offers cleaner billing and faster reimbursement. PlektonLabsClarity Ventures

Q2: How do standards like PACIO boost billing accuracy?

• PACIO’s medication profile and transitions guides ensure structured, trusted data flows between care settings and downstream billing systems. pacioproject.org

Q3: Aren’t hospitals already interoperable?

• While 70% of non-federal hospitals engage in sending, receiving, finding, and integrating data, consistent effective use is still lagging, especially for billing. techmagic.co

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SEO-Optimized Highlights (For Google and Busy Skimmers)

• Seamless data exchange between providers, payers, and patients reduces billing delays.
• FHIR APIs, PACIO, CMS frameworks are shaping the next wave of healthcare interoperability.
• Move from compliance to connection with real implementations, not just checkbox behavior.
• Vendor-neutral, governed data flows transform billing efficiency and patient trust.

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Call to Action: Let's Talk and Build Real Connection

Whether you're a CMIO, a billing leader, or in health IT—start building connections, not just systems. Check your data flows. Attend interoperability events. Bring together providers and payers. Make interoperability work for billing.

Get involved. Join the conversation. Be the change.

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Final Thoughts

Interoperability isn’t a checkbox—it’s a lifeline. By turning FHIR from theory into action, embracing working implementation, and demanding structured data that’s governed and portable, we empower better billing, smoother care, and healthier organizations.

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This Week’s References

1. CMS announced a “digital health ecosystem” initiative to enhance data sharing between patients, providers, and vendors. American Hospital Association
2. The HL7 FHIR Connectathon (July 15–17, 2025) highlighted real-life FHIR use cases for payer-provider connectivity. CMS
3. The PACIO Project released tested FHIR implementation guides for transitions of care and medication profiles, paving the way for smoother billing workflows. pacioproject.org

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About the Author

Dr. Daniel Cham is a physician and medical consultant with expertise in medical tech consulting, healthcare management, and medical billing. He focuses on delivering practical insights that help professionals navigate complex challenges at the intersection of healthcare and medical practice. Connect with Dr. Cham on LinkedIn to learn more: linkedin.com/in/daniel-cham-md-669036285

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