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The Importance of Interoperability in Healthcare Billing

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With the medical world in the midst of a digital revolution, interoperability is more important than ever. But how do we define this tech buzz word in the context of healthcare in a way that makes sense for practitioners? Simply put, interoperability is as it says, the ability for systems to communicate and operate together.  

Today, many practices are onboarding not only electronic health records and clinical tools, but practice management suites that assist with billing and compliance. With all these tools in a healthcare provider’s toolbelt, it’s critical that each software system work together securely. Without seamless communication, the benefits of these tools are greatly hindered. Let’s dive into the details of such a key concept, so you can make sure your tools are optimized.  

Interoperability and Digital Billing 

We’ve given a brief overview, but the technical definition of interoperability is this: the capability of various information systems, devices, and software to access, share, and integrate data in a systematic manner. When it comes to healthcare, interoperability should allow different programs to exchange information between organizations, healthcare professionals, and patients.  

Without interoperability, digital insurance billing would be impossible. And, similarly, it is interoperability that allows claim clearinghouses to be so beneficial. Since a clearinghouse functions as the middleman between insurance payers and healthcare providers, interoperability is at the core of what we do and allows tools like Apex EDI to provide smoother and simpler claim processing.  

Interoperability in the healthcare setting has three main levels:  

First level (Foundational) — at this level, two IT systems can communicate clearly and securely with one another. However, it only involves pure data sharing without advanced analysis or interpretation. For example, one system sends a blood test result to another system, which stores it “as is.”  

Second level (Structural) — at this level, two IT systems follow a set of requirements for format, syntax, and order of data sharing. It helps the receiving system interpret the data and find an appropriate place for it. For example, if a receiving system gets a prescription from e-prescribe software, it can auto-populate itself with the patient’s personal information, medication use history, etc.  

Third level (Semantic) — this highest level of interoperability doesn’t just allow the two systems to communicate information to one another. It gives them an opportunity to interpret and use it. For example, a laboratory sends a blood test result to a clinic. At a semantic level of interoperability, the clinic’s IT system can identify the contents, verify them, match the test to a patient, send a notification to the right physician, and even schedule an appointment.  

Interoperability is the foundation of universal health information exchange (HIE). There is a national HIE strategy supported by the government. The easiest way to ensure interoperability is to design a universal EHR software that can be used by all healthcare service providers. However, since this is impossible, plan B is to make high-level interoperability a requirement for each EHR system. 

Interoperability Rules for Healthcare    

In March 2020, the Department of Health and Human Services issued two interoperability rules to improve patient access to electronic health information. In short, these rules allow patients to access healthcare information at no cost. For software developers, it means that the health IT systems should be able to communicate with third-party users seamlessly.  

The rule also established Conditions and Maintenance of Certification requirements for health IT software developers.  

In December 2020, CMS proposed a new interoperability rule, according to which all Medicaid, CHIP, and QHP programs would need to have HL7 FHIR-based APIs (Application Programming Interfaces) to support data exchange and prior authorization. The proposal also contains an API standard for healthcare operations across the USA.  

In short, health IT systems must be designed to improve the electronic data exchange between providers, patients, and payers.  

nurse on laptop
Interoperability improves data interchange and offers benefits to providers and patients at every stage in the care journey. 


The office of the National Coordinator for Healthcare Information Technology (ONC) established a voluntary Health IT Certification Program. Together with the Centers for Medicare & Medicaid Services (CMS), ONC established standards that EHRs must meet to qualify for use in the Promoting Interoperability Programs (ex-Meaningful Use).    

This type of certification allows EHR or module users to be sure that the system they purchase doesn’t just guarantee security and data confidentiality but also ensures interoperability with other health IT systems.  

Opportunities and Incentives  

If your EHR isn’t certified, you can’t participate in certain incentive programs offered by CMS and its innovation center. For example, to participate in the newest CMS Innovation Center initiative, Primary Care First, you need to have 2015 Edition CEHRT.  

CMS has another payment incentive program, the Merit-Based Incentive Payment System, which encourages the use of CEHRT. It could help you attain 25 points allocated to Advancing Care Information reporting.    

With interoperability requirements becoming more and more important for compliance, CEHRT isn’t just an option anymore. It’s a necessity for all healthcare industry players.  

Why Does Interoperability Matter?   

With most medical records moving online, the systems’ ability to interact with each other is highly important. Besides staying compliant with the latest rules and offering high-quality services to the patients, interoperability allows clinics to optimize their work process and:  

  • Gain access to previous patients’ records to ensure a proper treatment course.  
  • Mitigate physician burnout by minimizing manual work.  
  • Reduce administrative costs associated with manual data exchange coordination.  
  • Provide patients access to their data in compliance with the interoperability rules.  
  • Minimize errors related to manual data exchange.  

As clinics switch to CEHRT to stay on top of their game and take advantage of incentives, ignoring interoperability may put yours ahead of the competition. Meanwhile, EHR providers that don’t ensure proper certification will fail to satisfy users.  

Taking Interoperability to the Next Level with the Right Software   

Appropriate interoperability is only possible with CEHRT software. Clinics that don’t use CEHRT software may face compliance issues. Meanwhile, EHR providers that don’t pass the necessary certification lose the opportunity to attract certain buyers.  

As the focus on interoperability is likely to increase, it’s more important than ever to invest in software that is not only going to add to your practice management arsenal, but it up to date on health IT compliance measures. To learn more about how interoperability and the Apex EDI clearinghouse solution, schedule a demo today.  



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