Payer Compliance Strategy and Digital Transformation

This document is a case study detailing how a leading US health insurance payer achieved compliance with the CMS-9115-F Patient Access Final Rule. The client, servicing over 5 million members, faced challenges in meeting compliance requirements due to a lack of in-house technical resources. The objectives included achieving compliance before the enforcement date, minimizing disruption to ongoing projects, and adopting FHIR standards for data exchange. The client engaged Smile Digital Health, which provided a FHIR-native Health Data Platform. Within three months, the client was compliant with the CMS-9115-F Rule and also prepared for the upcoming CMS-0057-F Rule. The implementation led to increased member engagement, streamlined operations, and enhanced capabilities for managing quality measures. The case study outlines how the client leveraged compliance solutions to support value-based care and improve operational efficiency, ultimately establishing a foundation for long-term success in a rapidly evolving healthcare landscape.