CMS’ Final Rule on Interoperability and Prior Authorization: Small Provider Perspective
On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) unveiled the long-awaited Interoperability and Prior Authorization final rule (CMS-0057-F), marking a significant step forward in healthcare data exchange and streamlining prior authorization processes. This rule impacts various stakeholders, including Medicare Advantage organizations, State Medicaid agencies, Medicaid Managed Care Plans, and Qualified Health Plan issuers on the Federally facilitated Exchanges.
Impacted Payers and Providers
Payers: The final rule affects a broad spectrum of payers, including Medicare Advantage organizations, State Medicaid agencies, Medicaid Managed Care Plans, CHIP Managed Care Entities, and Qualified Health Plan issuers on the Federally facilitated Exchanges.
Providers: Eligible hospitals and critical access hospitals participating in the Medicare Promoting Interoperability Program, as well as MIPS eligible clinicians participating in the MIPS Promoting Interoperability performance category, are among the impacted providers.
Key Provisions of the Final Rule
Patient Access API: The rule mandates the establishment of a secure and public-facing API, enabling patients to access their membership information, coverage details, claims data, and clinical and prescription formulary information.
Provider Access API: Payers are required to implement a Provider Access API, facilitating the exchange of claims and encounter data, USCDI data, and prior authorization information (excluding drug-related data) with healthcare providers.
Payer-to-Payer API: This provision mandates payers to share members' utilization and clinical data with their new payer when switching plans.
Prior Authorization API: Impacted payers must implement and maintain a Prior Authorization API, including features such as coverage requirements discovery, documentation templates and rules, and support for exchanging prior authorization requests and responses.
Improving Prior Authorization Processes: Payers are required to comply with measures aimed at enhancing prior authorization processes, including setting specific decision timeframes, providing reasons for denial, and reporting relevant metrics publicly.
Incentive Programs: New measures for electronic prior authorization (ePA) have been introduced for the MIPS Promoting Interoperability Performance Category and the Medicare Promoting Interoperability Program.
Compliance Deadlines
Prior Authorization API: Compliance date is set for January 1, 2027.
Improving Prior Authorization Processes: Compliance date is set for January 1, 2026.
MIPS Measures
For the performance period in CY 2027 or the MIPS payment year in 2029, participants in MIPS Promoting Interoperability performance category and Medicare Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals must adhere to electronic prior authorization measures. These measures are binary (yes/no) instead of numerator/denominator measures, requiring participants to report affirmative responses or claim exclusions.
Future Expectations
The Office of the National Coordinator for Health Information Technology (ONC) is anticipated to publish regulations incorporating API support into its Electronic Health Record (EHR) certification program, further advancing interoperability initiatives in the healthcare industry.
In summary, the CMS Interoperability and Prior Authorization final rule represents a significant stride towards achieving seamless data exchange and improving administrative processes in healthcare, ultimately benefiting both patients and providers alike.
Source: Wedi April 8th, 2024, Presentation “The Road to Interoperability and Prior Authorizations: Small provider Perspective.”