How Health Plans Can Leverage Modern Technology Systems to Gain Strategic Advantage and Remain CMS-0057-F Compliant
The implementation of the Interoperability and Prior Authorization Final Rule mandate (CMS-0057-F) in early 2024 is more than just a compliance requirement—it’s an opportunity for health plans to modernize and streamline their operations. But for payers still dependent on outdated and legacy technology systems, it can be difficult to turn requirements into regeneration opportunities.
This was the subject of a recent IDC white paper entitled, “Compliance with Prior Authorization Mandates is a Strategic Opportunity for Payers,” by Jeff Rivkin, IDC Research Director. In the report, Rivkin explains the importance of investing in modern, highly interoperable solutions, and how these solutions can be a true catalyst for digital transformation—a goal many health plans are striving to accomplish.
5 Key Prior Authorization Takeaways for Health Plans
Rather than viewing compliance with CMS-0057-F as a regulatory burden, health plan leaders can use it as an incentive for digital transformation. By investing in next-generation core administrative processing systems and care management platforms, health plans can achieve the following strategic advantages:
Trend 1: Operational Efficiencies through Integrated Systems
One of the key challenges posed by CMS-0057-F is the need to integrate disparate systems to support real-time data sharing and streamlined workflows. Health plans that invest in modern, integrated platforms can automate manual processes, reducing the administrative burden on staff.
For example, a transformational core administrative processing system, such as HealthEdge’s HealthRules® Payer, can automate prior authorization workflows, manage claims, and synchronize data between clinical and administrative systems. By unifying these functions, health plans can respond faster to authorization requests, improve accuracy, and reduce manual intervention.
Trend 2: Improved Provider Collaboration and Member Engagement
The transparency and data-sharing requirements of CMS-0057-F are designed to improve collaboration between health plans, providers, and members. Health plans that invest in robust care management systems can enhance provider communication, streamline care coordination, and ensure that members have timely access to the care they need.
A comprehensive platform like GuidingCare® from HealthEdge can facilitate this collaboration by providing providers with real-time access to patient data, including the status of prior authorizations. This reduces the back-and-forth communication often associated with the prior authorization process, accelerating approvals and improving the member experience.
Trend 3: Data-Driven Decision-Making and Reporting
CMS-0057-F places a significant emphasis on transparency, requiring health plans to report key performance metrics related to their prior authorization processes. Health plans that invest in business intelligence and analytics tools can not only meet these reporting requirements, but also use the data to optimize their operations.
By leveraging the robust reporting capabilities of a care management platform like GuidingCare, health plans can track key metrics like approval and denial rates, turnaround times, provider performance, and more. This data can be used to identify inefficiencies, make data-driven decisions, and continuously improve the prior authorization process—beyond remaining compliant with CMS-0057-F.
Trend 4: Scalability and Futureproofing
It is imperative that payers invest in a modular and agile technology platform to scale their operations alongside their growing member base. Legacy systems are often rigid and unable to adapt to changing regulatory requirements or market conditions. In contrast, forward-thinking CAPS and care management platforms are designed to be flexible, allowing health plans to easily adapt to new regulations or business needs.
Considering the ever-evolving Centers for Medicare & Medicaid Services (CMS) regulations, health plans that invest in scalable technology are better positioned to adapt to future changes without costly system overhauls. This futureproofing is essential for long-term operational success.
Trend 5: Choosing the Right Technology Partner
Investing in the right technology starts with finding the right partner. Look for highly interoperable solutions that work together seamlessly to offer real-time data sharing, support business rules engines, and deliver robust reporting and analytics capabilities.
While meeting the compliance requirements of CMS-0057-F is crucial, it also opens the door to much broader opportunities for health plans to become digital payers. By embracing modern, integrated technology platforms like those offered by HealthEdge, health plans can ensure compliance and also create a foundation for long-term operational success.
Learn more about how compliance with this new rule can be leveraged as a strategic opportunity for your organization. Download the full IDC whitepaper.
