For the past several years, the Centers for Medicare & Medicaid Services (CMS) has been working to improve interoperability—the seamless and secure flow of healthcare data among patients, providers, and payers.1 The goal of improved interoperability is to support more efficient coordination of healthcare by improving the exchange of information.2 Two related CMS rules have most affected interoperability. In this article, we look at the newer one, the CMS Interoperability and Prior Authorization Proposed Rule, including who it will affect, how it will affect payers, and what it’s designed to accomplish.
The previous rule in this effort was the CMS Interoperability and Patient Access Final Rule (CMS-9115-F), released in May 2020. This rule established policies to advance interoperability and access to health information for patients, providers, and payers. It required affected payers to create a Patient Access API based on Fast Healthcare Interoperability Resources (FHIR) standards, enabling patients to access their health information when they need it most.2,3 It also required payers to build standardized payer-to-payer APIs with the goal of allowing patients’ health data to follow them if they switched health insurance plans.1
CMS Interoperability and Prior Authorization Proposed Rule
Announced In December 20202,4, this proposed rule builds on the policies of the previous rule to improve data sharing and reduce burden on stakeholders by enhancing the prior authorization (PA) process.2 This proposed rule is scheduled to go into effect January 1, 2023.
This new rule is designed to give both payers and providers access to complete patient histories, reducing wasteful efforts, and allowing for more coordinated, seamless patient care.5 Similarly, this should streamline processes related to PAs while increasing patient access to their healthcare information.5
Together, these policies may play a key role in reducing overall payer and provider burden. Reducing provider burden gives physicians more time to focus on patients, enabling them to give better quality care.5 As more providers participate in value-based contracts, the lesser burden also means greater operational efficiencies, hence better financial results.
The CMS Interoperability and Prior Authorization Proposed Rule would apply to a select group of CMS-regulated payers:6
- Medicare Advantage (MA) organizations
- Medicaid Managed Care Plans
- State Medicaid Agencies
- Children’s Health Insurance Program (CHIP) Agencies
- CHIP Managed Care Entities
- Issuers of Qualified Health Plans (QHP) on the Federally-Facilitated Exchanges (FFEs)
The five proposals
- Patient Access API
The proposed rule would require affected payers to include information about patients’ pending and active PA decisions as part of the already established Patient Access API.7
- Provider Access API
The proposed rule would require affected payers to create a Provider Access API. This would be used to share data with providers pertaining to claims and encounters, including pending and active PA decisions.3,7 The proposed rule recommends use of Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) Bulk Data Access specification. Shared data would not include cost information.7
- Payer-to-Payer API
The Interoperability and Patient Access final rule (CMS-9115-F) specified that affected payers had to exchange and maintain patient health information between payers. This creates a longitudinal health record for patients, one that is maintained with their current payer. This final rule encouraged the use of an FHIR-based API for this data exchange, but did not require it.3,7
The proposed rule would alter the final rule to require use of an FHIR-based API for the Payer-to-Payer API. The proposed rule adds another requirement as well: The Payer-to-Payer API will be required to include information about patients’ pending and active PA decisions. It also proposes that payers would share this data at enrollment, so patients will automatically take their health information—including PA decisions—with them from one payer to the next.3,7
The goal of this portion of the proposed rule is for patients not to have to repeat the PA process when moving from one payer to another. They would not have to undergo repeat evaluations for reaffirming coverage or PA decisions, as the new payer would first review medical records and notes from the previous payer to see if and why a repeat test is needed.7
- Prior Authorization (PA) proposals
The proposed rule includes several proposals to make the PA process more efficient and transparent, with the goal of alleviating some of the administrative burden for providers and, at the same time, improving the patient experience.3,5,7
PAs have been identified as a major source of provider burnout and administrative waste and frustration. Although PAs are important for preventing fraud, abuse, and unnecessary expenditures, the current PA process also has many negative effects. Providers have to use significant staff resources, first to identify payers’ PA requirements and then to navigate the PA submission and approval processes—resources that could otherwise be devoted to improving clinical care.3,5
Under the proposed rule, payers will be required to include the specific reason for a denial when denying a PA request. The proposed rule would also require shorter PA timeframes: payers would need to send PA decisions within 72 hours for urgent requests and seven calendar days for standard requests, except for QHP issuers on the FFEs.5,7 Finally, to provide greater accountability for health plans, they would be required to publicly report data about the PA process, such as:3,7
The first set of these metrics would be reported March 31, 2023.3
- Percentage of PA requests approved, denied, and ultimately approved after appeal
- Average time between PA submissions and determinations
Together these requirements could lead to fewer PA denials and appeals. They are also intended to improve communication and understanding between payers, providers, and patients.5
- Proposal to adopt implementation specifications for all required APIs
The Office of the National Coordinator for Health IT (ONC) also has a Department of Health and Human Services (HHS) rider on the CMS proposed rule. This rider would require APIs to use certain implementation specifications to align with a nationwide health IT infrastructure. This infrastructure was created in support of reducing burden, reducing healthcare costs, and improving patient care.3,5,7
The Big Picture
All aspects of the CMS Interoperability and Prior Authorization Proposed Rule described above would go into effect starting January 1, 2023.3
The proposed rule should result in improved electronic exchange of health information among payers, providers, and patients. Both payers and providers will have access to patients’ complete health histories, reducing unnecessary care and allowing for more coordinated, seamless patient care. It will also streamline and bring greater transparency to processes related to PA.5 These changes would be made with the goals of:3,7
- Improving patients’ electronic access to health information
- Improving the PA process
- Ensuring that patients have a better understanding of the PA process and its impact on their care
The proposed rule will also strengthen several provisions of the CMS Interoperability and Patient Access final rule by requiring the APIs in this final rule to use FHIR-based specifications. This will improve interoperability and broaden the data each API is able to access.3,5,7
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- Brooks-LaSure C. Interoperability and the Connected Health Care System. Centers for Medicare & Medicaid Services (CMS). Updated December 8, 2021. Accessed December 13, 2021, https://www.cms.gov/blog/interoperability-and-connected-health-care-system.
- Policies and Technology for Interoperability and Burden Reduction. Centers for Medicare & Medicaid (CMS). Updated December 9, 2021. Accessed December 12, 2021, https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index.
- Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information CMS-9123-P: Fact Sheet. Centers for Medicare & Medicaid Services (CMS). Updated December 10, 2020. Accessed December 12, 2021, https://www.cms.gov/newsroom/fact-sheets/reducing-provider-and-patient-burden-improving-prior-authorization-processes-and-promoting-patients.
- Centers for Medicare & Medicaid Services (CMS). Medicaid Program; Patient Protection and Affordable Care Act; Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information for Medicaid Managed Care Plans, State Medicaid Agencies, CHIP Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges; Health Information Technology Standards and Implementation Specifications. In: Centers for Medicare & Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC), editors. p. 82586-82682.
- CMS Proposes New Rules to Address Prior Authorization and Reduce Burden on Patients and Providers. Centers for Medicare & Medicaid Services (CMS). Updated December 10, 2020. Accessed December 12, 2021, https://www.cms.gov/newsroom/press-releases/cms-proposes-new-rules-address-prior-authorization-and-reduce-burden-patients-and-providers.
- Interoperability and Patient Access Final Rule (CMS-9115-F) Frequently Asked Questions (FAQs). Accessed December 12, 2021. https://www.cms.gov/files/document/cms-9115-f-interoperability-and-patient-access-final-rule-compiled-faqs.pdf.
- Mugge A, Director and Deputy Chief Health Informatics Officer, CMS. CMS Interoperability and Prior Authorization Proposed Rule. https://www.healthit.gov/sites/default/files/facas/2021-01-13_CMS_Interoperability_and_Prior_Authorization_Proposed_Rule_Presentation.pdf.