Medicare Compliance & Reimbursement

Proposed rule aims to make data sharing easier for all.

The pandemic showed how the quick and safe exchange of patient data can be the difference between life and death. Now, building on its pre-COVID proposals, the Centers for Medicare & Medicaid Services (CMS) looks at connecting the dots between prior authorization and interoperability.

Background: In May 2020, CMS released the Interoperability and Patient Access final rule, which aimed to cut administrative burdens and costs while offering patients more access to and control of their health data (see Medicare Compliance & Reimbursement, Vol. 46, No. 12). On Dec. 6, CMS offered a follow-up to its 2020 release, broadening the original policies, clarifying provisions, and adding some new prior authorization proposals into the mix. The proposed rule was published in the Federal Register on Dec. 13.

“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” says  CMS Administrator Chiquita Brooks-LaSure in a release. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers — helping us to address avoidable delays in patient care and achieve better health outcomes for all.”

Here Are 3 Takeaways from the Proposed Rule

Health IT continues to shape healthcare, and CMS wants to utilize technology to make processes more efficient. Here are three key points to know in the proposed rule:

1. Prior authorization: Before practicioners can administer specific items and services, they have to request payer approval, CMS reminds in a fact sheet on the proposed rule. This administrative process can be burdensome and lead to provider burnout, causing care delays and endangering patients. Additionally, prior authorization requires extra staff and can be costly for providers — but also for patients. “Patients may unnecessarily pay out-of-pocket or abandon treatment altogether when prior authorization is delayed,” CMS says.

In an attempt to alleviate these longstanding prior authorization issues, CMS proposes the following, according to the rule:

• Require impacted payers to list their specific denial reasons for refusing prior authorization.
• Mandate impacted payers utilize Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) Patient Access API to automate the prior authorization process.
• Fast track the prior authorization process, keeping it with 72 hours for expedited requests and seven days for regular requests.
• Promote transparency by requiring payers to publicly report their prior authorization statistics via a Patient Access API.
• Add a new prior authorization measure for MIPS-eligible clinicians and for eligible hospitals and critical access hospitals (CAHs) in the Promoting Interoperability programs.

2. Provider Access API: As CMS continues to focus policies on cost and coordination, the proposed rule aims to connect interoperability and value-based payment models. “We are proposing to require impacted payers to build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship,” the fact sheet notes. If finalized, payers would need this to be up and running by Jan. 1, 2026.

3. Data exchange: CMS wants patients to have access to their data when they change insurers or providers. “In an effort to ensure a patient’s data can follow them throughout their health care journey, we are proposing to require that payers would exchange patient data when a patient changes health plans with the patient’s permission,” CMS says. “Those data would include claims and encounter data (excluding cost information), data elements identified in the USCDI version 1, and prior authorization requests and decisions,” the fact sheet clarifies.

The proposed changes target Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) agencies, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) and aim to bolster interoperability in these programs. The proposed rule also includes five Requests for Information (RFI) on a variety of issues from social risk data standardization to electronic exchanges of behavioral health data that concern the Medicare fee-for-service program.

CMS is accepting comments on the rule through March 13, 2023.

Resources: Find the proposed rule at www.federalregister.gov/public-inspection/2022-26479/medicare-and-medicaid-programs-advancing-interoperability-and-improving-prior-authorization and the fact sheet at www.cms.gov/newsroom/fact-sheets/advancing-interoperability-and-improving-prior-authorization-processes-proposed-rule-cms-0057-p-fact.