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The Promising Convergence of Payer Strategy and Compliance with the CMS Interoperability and Prior Authorization Final Rule

Payer Doctors

What are the top initiatives in your payer organization? Enhancing your Star ratings? Strengthening your provider network? Addressing health equity issues? Gartner’s most recent healthcare benchmark numbers show that in Q1 2024, quality improvement, data and analytics, behavioral/mental health, and risk adjustment optimization are the top initiatives for most US payers. But that same survey identifies regulatory shifts as the top factor driving enterprise decision making. 1

Regulatory requirements are often seen as a distraction from “more important” organizational initiatives. In some cases, though, such mandates align well with business priorities and provide the necessary urgency to move key initiatives forward. Approached from the right perspective, new regulatory requirements can be harnessed to put in place infrastructure and business processes that will strengthen the enterprise for years to come. The CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F, released in January 2024, represents just such an opportunity for payers.

The new rule is the latest in a set of regulatory initiatives to deploy the necessary infrastructure for the collaboration and data sharing needed to support value-based care. In 2009, the HITECH act digitized and normalized provider EHR data. In 2020, CMS-9115-F introduced API-based information sharing by payers. Now, CMS-0057-F mandates the use of digitized data and APIs to advance interoperability among all key stakeholders and automate costly manual prior authorizations. While targeted at a specific set of federally funded “impacted payers,” it is expected to have a ripple effect across the entire health care industry.

As the name implies, the rule requires investment by impacted payers in interoperability infrastructure, but it would be a mistake to simply delegate implementation to the Information Technology (IT) team. The mandated application programming interfaces (APIs) are accompanied by a host of aggressive operational, policy, and workflow requirements affecting the entire business.

More specifically, CMS-0057-F addresses four types of information sharing by impacted payers:

  1. Sharing information with other payers, both impacted and non-impacted, to build longitudinal patient records for better care coordination.
  2. Sharing information with members and their representatives to better manage and coordinate their own care.
  3. Sharing information with in-network treating providers to make available relevant context and visibility about a patient’s care team and clinical history.
  4. Digitizing the information sharing required for prior authorization to streamline and automate a costly and burdensome set of processes.

All building, and building on, a longitudinal health record. You can picture the core requirements for impacted payers like this:

Impacted Payers

Figure 1 CMS-0057-F Overview

Collectively, these four required types of information sharing imply a fifth requirement: the deployment or expansion of a longitudinal health record that can integrate member clinical, claims, and social determinants of health data. This represents one of the greatest opportunities to advance priorities like quality improvement, analytics, and risk adjustment optimization while addressing regulatory compliance. According to IDC’s Jeff Rivkin:

Well-documented payer walls between the "claims side of the house and the care side of the house" are highlighted with prior authorization. A strategy to comply to the final rule issued by the U.S. Centers for Medicare & Medicaid Services suggests that payers should unify organizations and systems around their member longitudinal health record.

Ensuring your organization’s response to CMS-0057-F simultaneously safeguards compliance and advances business strategy will require alignment between IT, clinical, and business leadership, under the guidance of your regulatory team, as depicted below.

Cross Functional Payer Compliance Team

Figure 2 Cross-Functional Payer Compliance Team Recommended for Rule Compliance

So, what are your highest priority initiatives? How might your priorities converge with your compliance plans?

  • Improving member experience? A rapid, stress-free prior authorization experience would go a long way to helping with that.
  • Improving data and analytics or leveraging machine learning for better predictive capabilities? A robust member 360 longitudinal record would be a solid foundation.
  • Improving collaboration with your provider network?  Helping them improve care management by sharing member data, and then streamlining HEDIS reporting and reducing the data collection burden on them using your longitudinal health record would be a valuable investment. And of course, reducing prior authorization headaches is even more important to your providers than most of your members.

The “burning platform” of regulatory mandates doesn’t always intersect with your strategic priorities. But this time around, things look pretty promising!

1 Bishop, M, 1Q24 U.S. Healthcare Payers Enterprise Benchmarks: Priorities and Technology Deployments, Gartner, 1 March 2024- ID G00809883

Originally published by Fierce Healthcare:

Andere Berichten Die Je Misschien Leuk Vindt.