Back in May 1, 2020, The Centers for Medicare & Medicaid Services (CMS) introduced the Interoperability and Patient Access Final Rule. The rule aimed to improve healthcare quality provided by improving patients’ access to their healthcare information. By adopting the patient-first approach, CMS believed it would help patients make informed care decisions.
While Interoperability and Patient Access final rule established policies that promised to improve upon the exchange of healthcare data and thereby saving up time and cost for providers, patients, and payers – it had loopholes of its own which rendered the policies not-as-successful. There were still issues stemming from interoperability, pushing those involved in the healthcare eco-system to request for a better-defined rule, addressing the shortcomings of the IPA final rule.
- For the APIs introduced in IPA, there were no mandatory implementation guides – resulting in the lack of standards when it came to sending, receiving, and managing information between programs and payers.
- Unavailability of any measurement standards concerning the introduced APIs, allowing scope neither for understanding if they are useful to the patients nor for improving the API functionalities. To address the shortcomings and ensure seamless interoperability, the CMS has come forth with a proposed rule – Reducing Provider and Patient Burden.
Before delving into the proposals, let’s take a beat to look at what prior authorization is and the challenges it currently poses.
Prior Authorization and its Challenges
Prior authorization is the process where the provider seeks approval from the payer, before providing services and receiving the payment for the rendered services or items. While the IPA improves patient access to information, it does little or nothing to alleviate the provider and payer burden. When it comes to prior authorization, these are the few challenges that went unaddressed:
- Providers and clinic staff spent too much time submitting a prior authorization request through complex channels like fax or telephone.
- Payers took too long to respond with a decision on the prior authorization request, leading to delayed care resulting in health risks.
- Lack of clarity in payer-specific requirements when it comes to items and services that require prior authorization.
Reduce Provider and Patient Burden
The latest proposed rule to reduce the burden on providers, patients, and payers aim to achieve the following:
- To improve electronic exchange of healthcare data (specifically, prior authorization decisions), among payers, providers, and patients
- Implementation of APIs to reduce prior authorization burden, reducing time for the same ensuring faster access to healthcare
- Implementation of APIs to provide patients control over data sharing
- Reduce the administrative burden of all parties involved, by providing access to data that would help them make informed care decisions quicker
- Implementation Guides for APIs to be made mandatory to standardize electronic healthcare data sharing
- Drive interoperability and improve care coordination
The latest proposed rule, Reducing Provider and Patient Burden have a set of proposals and requests for information. The proposals are as below, and the request for information can be discussed later on.
The Proposals
Patient Access API
Building on the Patient Access API mandates mentioned in IPA, payers are expected to include a patient’s pending and active prior authorization decisions.
Provider Directory API
According to the proposal, the Provider Directory API finalized in the IPA is to be conformant with the FHIR Da Vinci PDex Plan Net IG: Version 1.0.0.
Provider Access API
Payers are expected to develop and maintain a new API to allow payer-to-provider data sharing, which includes claims, encounter data, clinical data, and prior authorization decisions, both active and pending.
Payer-to-Payer Data Exchange
The CMS has proposed a payer-to-payer API, which comes as an addition to the already existing APIs that were confirmed in IPA. Payers must make claims and encounter data, and information about pending and active prior authorization decisions, in addition to those already outlined, available to other payers on a patient’s request in cases of churn.
Documentation and Prior-Authorization Burden Reduction Through API
Payers must introduce APIs to allow providers to locate prior authorization requirements, send and receive prior authorization requests, and respond electronically. The new APIs proposed are Documentation Requirement Lookup Service (DRLS) API and Prior Authorization Support (PAS) API.
Adoption of Health IT Standards and Implementation Specifications
To ensure payers align with the nationwide health IT infrastructure, reduce the burden on stakeholders, healthcare costs, and improve the quality of care, they are expected to adopt standards and implementation specifications with regards to the APIs.
What we can do
Nalashaa has been involved in the healthcare IT ecosystem for a good while now, empowering our teams to be masters in the latest developments within the industry. The proposals released by the CMS on reducing provider and patient burden will soon be released as a final rule. Enable your IT systems and get your workflow process in line with the proposed rules, making compliance easier once the final rules are announced.
Connect with us at info@nalashaa.com, and let us discuss how we can help you reduce the burden of your payers and associated providers to offer improved quality healthcare to your members.
Shireen Noushad