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Shifting Regulatory Environment Calls for Vigilance

The machinery of the regulatory world grinds forward and compliance deadlines come and go. The ambitious interoperability and transparency regulations that are reshaping key elements of the industry are under continual interpretation and review by HealthEdge staff. We are holding focus groups and facilitating an ongoing dialogue with our customers to stay on top of their concerns and shed light on developments as they occur.

Everyone has more questions than answers right now. The regulatory environment is in a bit of a holding pattern because so many things have been paused, but that doesn’t mean our work to prepare is wasted. We need to stay vigilant but not get ahead of ourselves.

As an example, one focus group participant recently asked us how regulators in a fluid environment will assess whether health plans are complying with Transparency in Coverage Machine Readable Files if records are not included. Regulators want to see a “good faith” effort by health plans. If a record is missed because a reasonable algorithm missed it, the plan has not failed compliance, because they made a good faith effort. But they would be expected to correct this as soon as practical.

We are continuing our technical work as scheduled and encourage plans to stay committed during this time. The additional time will ensure that the “unknowns around the requirements” not yet presented through rulemaking are thoughtfully created, while we stay focused on the enhancements that will assure compliance with the requirements and beyond. The one thing no plan should do is sit back and wait for the pieces to fall into place. If there’s anything that 2020 and 2021 have taught us, it’s to expect the unexpected!

HealthEdge, GuidingCare® and Source® customers who wish to dialogue with HealthEdge as we develop compliant solutions should reach out to their Account Executives. Focus groups are held Thursdays at 11:30 a.m. ET, usually covering a single topic. The No Surprises act is slated for discussion Dec. 2, with Machine Readable Files to be covered Dec. 16. January 2022 topics are in the works.

About the Author

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.