Payers are rightly reaching out to InterSystems with a host of implementation questions about the Prior Authorization API recently mandated by the Interoperability and Prior Authorization Rule (CMS-0057-F). Current prior authorization processes are frustrating and burdensome to providers, patients, and plans, and the changes now required by CMS are intended to automate needed information flows and meaningfully reduce provider abrasion. Nonetheless, the positive impact of the Payer-to-Payer API also required by the rule should complement that of the Prior Authorization API, if properly leveraged.
A Needed Mechanism for Safeguarding Care Continuity
Data gaps and siloes have long stymied care continuity and value-based care. These challenges are particularly acute for the roughly one-fifth of plan members who experience coverage disruptions or change plans each year. More specifically, their records frequently don’t follow them to their next plan, resulting in the loss of authorizations for planned services, repeating of therapies already shown to be ineffective, and costly gaps in care, particularly for members with chronic conditions. The Payer-to-Payer API provides a mechanism for enabling the timely flow of member data to new plans and between concurrent plans.
In short, the rule requires impacted payers to develop and maintain a FHIR-based API that other payers can readily utilize to retrieve information about their new or concurrent members. Data elements that must be shared include information about prior claims, encounters with capitated providers, and active prior authorization requests as well as clinical data maintained by the payer. CMS also requires impacted payers to incorporate into longitudinal health records the data of members opting-in to payer-to-payer information sharing and strongly encourages all non-impacted payers to participate as well. In fact, it has indicated that Medicare fee-for-service, a non-impacted payer, will support this API.
Achieving Larger Returns on Mandated Investment
Development and maintenance of a compliant Payer-to-Payer API, however, is not the only hurdle payers must overcome to safely and securely achieve the benefits of unlocking information flow among payers. Like the Prior Authorization API, the rule enumerates multiple complex operational requirements that also must be addressed. For example, at least impacted payers must develop and maintain mechanisms to link members with other payers, secure and store informed member consent for data sharing, ensure IT systems can integrate data from other plans into longitudinal or unified care records, and equip case managers with tools to act on this influx of information in a timely manner.
For payers looking for a starter set of questions to expand discussion about the Payer-to-Payer API from compliance to driving value-based care, InterSystems suggests the following five:
Five Key Questions to Maximize Your ROI in the Payer-to-Payer API
1. What are your best alternatives for streamlining documentation of opt-in status and prior enrollment of new members?
2. Can your current systems incorporate retrieved information into a single longitudinal health record for each member?
3. What tools do frontline staff need to act on data from other payers to improve care continuity for new and concurrent members?
4. How will you match member identities for exchanging data with other payers?
5. What is your strategy for testing connections with other payers?
Discussion participants should include leaders from your IT, clinical, operational, and regulatory teams. Successful resolution of these questions, plus many others, will require close alignment among these departments.
Originally published by Fierce Healthcare
