New CMS interoperability rule would streamline prior authorization processes

The proposed rule aims to enhance patient access and smooth API-enabled data exchange by requiring the use of specific HL7 FHIR implementation guides by payers.
By Kat Jercich
11:43 AM
Seema Verma

The U.S. Centers for Medicare and Medicaid Services issued a proposed rule Thursday aimed at improving the electronic exchange of healthcare data among payers, providers and patients.

The rule would require Medicaid, CHIP and QHP programs to build HL7 FHIR-based APIs to support data exchange and prior authorization. It also includes a proposed API standard for healthcare operations nationwide.

"For patients, there will be no more wrangling with prior providers and locating ancient fax machines to take possession of one’s own data; for providers, there will be no more piecing together patient health histories based on incomplete, half-forgotten snippets of information pried out of the patients themselves; for payers, this is the first step towards building the important data sharing systems we need to move towards value," wrote CMS Administrator Seema Verma in a blog post accompanying the announcement.   

WHY IT MATTERS  

The proposed rule seeks to enhance the patient access API by requiring the use of specific HL7 implementation guides by impacted payers.

"If these IGs remain optional, there is a chance that the required APIs could be built in such a way that creates misalignment between and among payer APIs and with third-party apps," noted CMS in the rule text.

In addition, CMS is proposing that payers establish, implement and maintain a process ensuring that third-party app developers requesting to receive patient data will adhere to certain privacy provisions.  

It also would require some payers to build a FHIR-based API allowing providers to know in advance what documentation is needed, to streamline the documentation process, and enable providers to send prior authorization requests and receive responses electronically, directly from the provider’s EHR or other practice management system.

The rule proposes a maximum of 72 hours for payers to issue decisions on urgent requests and seven calendar days for nonurgent ones, with a requirement to provide a specific reason for any denial.  

"These policies, taken together, could lead to fewer prior authorization denials and appeals, while improving communication and understanding between payers, providers, and patients," wrote CMS in a press release.

The rule also includes a proposal on behalf of the Office of the National Coordinator for Health IT to adopt the API implementation specifications for healthcare operations as part of a nationwide health IT infrastructure.  

"By ONC proposing these implementation specifications in this way, CMS and ONC are together working to ensure a unified approach to advancing standards in HHS that adopts all interoperability standards in a consistent manner, in one location, for HHS use," read the rule.  

THE LARGER TREND

The rule builds on final rules around interoperability and patient access, themselves aimed at fulfilling provisions of the 21st Century Cures Act.

Although the COVID-19 pandemic provoked some agency flexibility around timeline and compliance, it also highlighted the importance of seamless information sharing.   

Patients have also expressed high levels of interest in having access to their own data.  

ON THE RECORD

"If just a quarter of providers took advantage of the new electronic solutions that this proposal would make available, the proposed rule would save between 1 and 5 billion dollars over the next ten years. With the pandemic placing even greater strain on our health care system, the policies in this rule are more vital than ever," said Verma in a press release.
 

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Email: kjercich@himss.org
Healthcare IT News is a HIMSS Media publication.

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