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Are You Ready to Meet
the New CMS Interoperability Rules?

“While the new CMS rule presents significant implementation challenges, effective compliance will position payers to deliver health value to members by empowering them to orchestrate their data across the ecosystem and manage their own health more effectively. Think of interoperability as an opportunity to transform relationships with members rather than simply checking the box for compliance with the regulatory mandate.” 

“Prepare for CMS Interoperability and Patient Access API Compliance for U.S.Healthcare Payers.”
Published 15 June 2020 – ID G00725481, Analyst Mandi Bishop

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Health Insurance 2.0: Modernizing the Value Proposition

Presented by The Economist Events

InterSystems HealthShare CMS Solution Pack

See What Analysts Are Saying

Several analysts have noted that InterSystems is among the vendors who have what it takes to meet the requirements of CMS Rule 9115-F.

In this Gartner research report, “Prepare for CMS Interoperability and Patient Access API Compliance for U.S. Healthcare Payers”, analyst Mandi Bishop highlights the key requirements of the rules as well as raises key concerns and considerations that payers must tackle.

A Solution to the Interoperability and Patient Access Challenges
of CMS Rule 9115-F

InterSystems HealthShare® CMS Solution Pack is a turnkey product that provides a simplified way to meet the final rule 9115-F requirements, supporting the rule’s use cases for 2021 and 2022:

  • Patient Access APIs – Giving patients access to their own claims, clinical, and pharmacy benefit information (2021)
  • Provider Directory API – Online provider and pharmacy directory access (2021)
  • Payer-to-Payer Data Exchange (2022)

The Solution Pack is based on all of the implementation guides referenced in the final rules and includes a FHIR 4.0.1. gateway, full support for the USCDI clinical data set, and the required privacy and security standards.

Unlike competing solutions, the Solution Pack includes a path to address broader use cases using our full InterSystems HealthShare product suite. HealthShare can, for example, provide data and analytics for HEDIS reporting and Risk Adjustment.

HealthShare CMS Solution Pack

The Solution Pack’s powerful data aggregation, normalization, and deduplication technology are key to unifying information from diverse sources and enabling each use case specified by rule 9115-F.

Patient Access APIs

The InterSystems HealthShare CMS Solution Pack takes your required claims, clinical, and pharmacy benefit data, regardless of its format, and transforms it into FHIR 4.0.1 representations. Third-party applications using FHIR application programming interfaces (APIs) provide access to this data.

The solution meets the Patient Access API requirements via:

  • Clinical data mapping to USCDI v1 data types, including the new clinical notes, pediatric vital signs, demographics, provenance and lab results
  • Claims data mapped according to the CARIN Alliance, Blue Button 2.0 specification
  • Formulary data using the HL7 Da Vinci implementation guide
Interconnected Dots

Provider Directory API

InterSystems HealthShare CMS Solution Pack transforms your provider directory data to FHIR, including plan, names, network status, addresses, phone numbers and specialties, as well as pharmacy directory data for Medicare Advantage and Medicaid Plans. Our Da-Vinci PDEX Plan-Net FHIR APIs make the detailed care landscape of provider and pharmacy directory information accessible as required by the rule.

Payer-to-Payer Data Exchange

Although not a requirement until 2022, the Solution Pack supports data ingestion from another payer (as directed by the member) in any electronic format, for the data specified by the USCDI standard. It can store a member-centric longitudinal record for the member’s past and current data and can securely send that data along to another payer (as directed by the member) in the same format as received, or any other required format.

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Provisioned in your cloud, on premise, or as a managed service, a HealthShare CMS Solution Pack deployment includes InterSystems implementation services to get you up and running with minimal burden on your IT staff.

The solution currently is available for use by customers in the United States only.


Improving Care Coordination & Management

Chronically ill patients with highly fragmented care cost almost double that of patients whose care was well coordinated, and were more likely to have preventable hospitalizations.

The Benefits of Real-time, Comprehensive Clinical Data

Giving case and care managers access to clinical data in a unified care record, like that provided by InterSystems HealthShare, allows them to share insights on patients and a care plan for better coordination.

HealthShare’s unified care record, receiving real-time clinical feeds, can send out alerts on inpatient and emergency department admissions to the primary care provider and the payer. The alerts enable better care coordination for the patient, and automatic enrollment through HealthShare into care management programs. The clinical data also can populate Care Management/Utilization Management systems, assuring current and accurate information.

Doctor working on a tablet.

Enhancing Quality & Streamlining Measurement

Improvement happens continuously, not 90 days ago. Clinical data gives you the information and perspective needed to make course corrections. Recognizing this, NCQA recently created a draft specification that expands HEDIS measurement to support clinical data, with 2019 as the first year that they will accept data directly from clinical systems for a limited set of measures.

Real-time clinical data from HealthShare can feed HEDIS and STARS quality measures, allowing for continuous monitoring and improvement.


Optimizing Network Performance

As a health plan, your greatest asset is your provider network. The more they provide cost effective quality care to members, the better it is for everyone. The key is transparency in data sharing: Making it possible for providers to see how they are performing against value based contracts, giving them insight into a longitudinal view of the care record, and helping them to succeed.

Making Operational Processes More Efficient

Which manual payer/provider process cries out for automation? If you said prior authorization you’re not alone. The prior authorization process costs $23 to $31 billion per year in the US, according to a 2009 study published in Health Affairs. The health plan cost per manual prior authorization is $3.68, compared to $0.04 per electronic prior authorization, according to a 2017 Chilmark Research report.

It’s not just the bank account that suffers. Delays in the process affect provider morale and patient care. Combined, physicians and nurses spend about three and 13 hours a week, respectively, dealing with prior authorizations – time better spent with patients.

Reimagining this and other processes to make them more efficient requires access to clinical data. Examples, in addition to prior authorization and utilization management, include compliance with state or federal programs such as lead screening, and eliminating the HEDIS chart chase.

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