CMS Rule
Building on the CMS Interoperability and Patient Access final rule (CMS-9115-F), this proposed rule would place new requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of health care data, and streamline processes related to prior authorization.
This rule will require maximum patient electronic access to their healthcare information, and this may improve the electronic exchange of health information among payers, providers and patients.
These policies can play a key role to reduce overall payer and provider burden and improve patient access to health information.
Patient Access Application Programming Interface (API)
This proposed rule would also require impacted payers to establish, implement, and maintain an attestation process for third-party application developers to attest to certain privacy policy provisions prior to retrieving data via the payer’s Patient Access API.
And, this rule would require impacted payers to report metrics quarterly about patient use of the Patient Access API to CMS to assess the impact the API is having on patients.
Provider Access APIs
In order to better facilitate coordination of care, and in support of a move to value-based care, CMS proposing to require impacted payers to build and maintain a Provider Access API for payer-to-provider data sharing of claims and encounter data (not including cost data), a sub-set of clinical data as defined in the U.S. Core Data for Interoperability (USCDI) version 1, and pending and active prior authorization decisions for both individual patient requests and groups of patients starting January 1, 2023.
Documentation and Prior Authorization Burden Reduction through APIs
Patients may unnecessarily pay out-of-pocket or abandon treatment altogether when prior authorization is delayed. In an attempt to alleviate some of the administrative burden of prior authorization and to improve the patient experience, CMS proposing a number of policies to help make the prior authorization process more efficient and transparent.
Payer-to-Payer Data Exchange on FHIR
In the Interoperability and Patient Access final rule (CMS-9115-F), CMS finalized a requirement that, at a patient’s request, CMS-regulated payers must exchange certain patient health information, and maintain that information, thus creating a longitudinal health record for the patient that is maintained with their current payer. While CMS encouraged the use of a FHIR-based API for this data exchange.
Accelerating the Adoption of Standards Related to Social Risk Data
CMS request information on barriers to adopting standards, and opportunities to accelerate adoption of standards, related to social risk data. CMS recognize that social risk factors influence patient health and health care utilization. And, CMS understand that providers in value-based arrangements rely on comprehensive, high-quality social risk data. Given the importance of these data, CMS look to understand how to better standardize and liberate these data.
The proposed rule is available to review today at: https://www.cms.gov/files/document/121020-reducing-provider-and-patient-burden-cms-9123-p.pdf
For more information on the CMS proposed rule, please visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index
