A strategy to comply with the final rule issued by the U.S. Centers for Medicare & Medicaid Services suggests that payers should unify organizations and systems around their members' longitudinal health records.
What's Important
- The U.S. Centers for Medicare & Medicaid Services recently finalized a proposed rule designed to speed the electronic exchange of information, streamline the processes related to prior authorization, and improve patient care.
- Data factory approaches, master data management techniques, and data fabric payer technology trends have been accelerated by these mandates.
- Organizations should allow requirements around mandates to be a driver of innovation instead of a necessary evil to be dispatched.
Introduction
The U.S. Centers for Medicare & Medicaid Services (CMS) recently finalized a regulation that includes mandates designed to speed the electronic exchange of information, streamline the processes related to prior authorization (PA), and improve patient care.
As part of CMS-0057-F, CMS finalized proposals for payers to:
- Implement and maintain an application programming interface (API) to support and streamline PA processes, respond to requests within certain time frames, provide a specific reason for denials, and publicly report on approvals, denials, and appeals.
- Expand the payer-to-patient data access API that was put in place to address earlier mandates. The API must now share information about patient PA decisions to help patients understand their payer's PA process and its impact on their care.
- Deploy a payer-to-payer data exchange access API to share patient data (with the patient's permission) when a patient has multiple health plans or changes health plans. Data includes claims and encounter data (excluding costs), data elements described in U.S. Core Data for Interoperability v1 (USCDIv1), and PA requests and decisions.
- Deploy a payer-to-provider data exchange access API to share patient data with in-network providers with existing patient treatment relationships. Data includes patient claims and encounter data (excluding costs), data elements described in USCDIv1, and PA requests and decisions.
In short, these four mandates mean shorter turnaround times for prior authorizations, increased transparency and reporting requirements, and new standards and collaboration requirements around PA submissions and data exchanges.
Key Takeaway
What is not stated but is heavily implied in the CMS ruling is the architectural implication that the payer-to-payer API is intended to be used by payers to populate longitudinal health records for their members, effectively a fifth requirement.