Healthcare interoperability is often described as a technology challenge—but for health plans, the real issue isn’t moving data between systems. It’s ensuring that the data being exchanged has consistent meaning, accuracy, and context across platforms and stakeholders.
In this episode of Regulatory Joe, Joe Boyle speaks with Will Tesch, CEO and Founder of TESCHGlobal and HealthLX, to break down why interoperability efforts stall even after APIs are live, what semantic accuracy actually looks like in practice and how upcoming requirements—especially around prior authorization—are raising the bar for operational readiness.
Healthcare Interoperability Isn’t a Data Transport Problem
Interoperability challenges can be compared to two people speaking different languages: even if the message is delivered successfully, the exchange breaks down if the receiver can’t interpret it the same way the sender intended. In healthcare, those breakdowns have real consequences, affecting care coordination, coverage decisions, audits, member experience, and regulatory compliance.
This is where semantic reference and canonical data models come into play. After working through multiple CMS interoperability implementations—including the CMS Interoperability and Patient Access Final Rule (CMS-9115-F)—Will’s team open-sourced a production-grade canonical data model known as CoCo. The goal is to provide a stable reference point, so organizations aren’t just exchanging data but exchanging data with shared meaning.
Where Interoperability Breaks Down Inside Health Plans
Over time, health plans have invested in a wide range of operational systems over the years: claims, care management, EDI processing, data warehouses, and vendor platforms. The challenge is integrating them in a way that produces consistent, reliable data for required APIs.
Smaller or leaner teams often don’t have the resources to build and maintain custom interoperability infrastructure, making faster, partner-led implementations more appealing. Regardless of approach, plans still face the same underlying requirement: data must be normalized and standardized well enough to support CMS-mandated APIs accurately and consistently.
Interoperability initiatives frequently expose a deeper issue—many organizations lack a true single source of truth. Without it, API outputs may technically meet requirements while still producing inconsistent or unreliable results downstream.
Healthcare Interoperability’s Next Challenge: Digitizing Prior Authorization
While many health plans initially focused on standing up endpoints to meet CMS-9115-F requirements, industry attention is now shifting to the CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F).
Under this rule, impacted payers are required to implement standardized, API-enabled prior authorization workflows, with compliance deadlines extending into 2027. In practice, this is far more complex than exposing a new endpoint. Prior authorization logic is often fragmented across utilization management systems, claims platforms, configuration rules, and manual workflows.
Prior authorization interoperability requires plans to clearly define how decisions are made, align UM and claims operations and produce proper automated responses. That discovery work can be time-consuming, but it is essential for understanding how an organization actually operates day-to-day.
Interoperability Recommendations for Health Plans
- Stop treating interoperability as “API plumbing.” Make semantic accuracy a first-class requirement. If the meaning isn’t consistent, the pipe doesn’t matter.
- Define (or rebuild) your single source of truth. Whether it’s a warehouse-led model or something else, your downstream APIs will only be as reliable as the data foundation feeding them.
- Bake interoperability commitments into contracts. If vendors don’t have clear obligations to deliver compliant, usable data outputs, plans inherit the risk.
- Start prior authorization discovery work now. The sooner teams map rules, systems, handoffs and denial logic, the more realistic the path to digitized automation becomes.
- Plan for enforcement variability. Even if federal enforcement feels slow, state scrutiny could kick in sooner. Build your roadmap assuming increased enforcement pressure.
Be sure to watch the full episode to hear all of Will’s insights on healthcare interoperability for health plans.
