Over the past several years, health plans have been hit by a tsunami of regulatory changes, and two primary themes have emerged: transparency and interoperability. From the Transparency in Coverage Act to the No Surprises Act, CMS has made it clear that the collection, retention, and use of electronic data that can improve the member experience, improve health outcomes, and reduce inefficiencies are top priorities for years to come. This blog highlights some of the most recent regulations, proposed rules, and payer interoperability.
- Machine Readable Files: It has been one year (July 1, 2022) since the Transparency in Coverage Final Rule went into effect. This rule requires health plans to make pricing data available, free of charge, to the public in Machine Readable Files. According to an April 2023 American Hospital Association article, more than 200 payers have posted machine readable files, up from only 68 in July 2022. This data now represents all sites of service, and more than 95% of commercially insured lives in the United States.The HealthRules Payer product team made these capabilities available to its customers via APIs and continues to make enhancements to improve processing time for the creation of these mega files. Our professional services team ensures a smooth transition for HealthEdge clients.
- Price Comparison Tool: The first phase of this rule, which went into effect January 1, 2023, required health plans to make 500 shoppable items accessible to members. The final phase is scheduled to take effect on January 1, 2024, and will require health plans to make pricing available for all shoppable items covered.Again, the HealthRules Payer teams are making compliance easy with advanced API and specialized services. In addition, for customers who choose to use other solutions, the team is prepared to support customers’ compliance efforts.
While interoperability is not a new topic within the healthcare industry, a wave of proposed rules focused on facilitating the exchange of health data between patients, providers, and payers are proving to be formidable challenges for payers dependent on legacy or outdated technology.
While the industry anxiously awaits the final rule on interoperability, health plans must prepare now to support more advanced interoperability goals.
- Electronic Prior Authorizations: According to the CMS announcement in December 2002, the proposed rule aims to improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. It requires payers to implement an electronic prior authorization process, which will shorten the time payers can take to respond to prior authorization requests and establish policies to make the prior authorization process more efficient and transparent. The rule also supports the development of standards that payers will follow when exchanging data, making it easier to ensure complete patient records are available when transitioning between payers.The mechanism the rule uses to enforce the mandate will be APIs. More specifically, the proposed rule will require health plans to use a Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorizations. By providing standards that all health plans must use, it is likely that in the long run, the rule will be more effective.
- Interoperability Standards: According to CMS, the proposed policies in this rule would also enable improved access to health data, supporting higher-quality care for patients with fewer disruptions. These policies include: expanding the current Patient Access API to include information about prior authorization decisions; allowing providers to access their patients’ data by requiring payers to build and maintain a Provider Access FHIR API, to enable data exchange from payers to in-network providers with whom the patient has a treatment relationship; and creating longitudinal patient records by requiring payers to exchange patient data using a Payer-to-Payer FHIR API when a patient moves between payers or has concurrent payers.HealthRules Payer customers will be able to use the advanced set of APIs from HealthEdge to comply with the final rule.
Additional regulatory changes are coming to the Medicare Advantage Designated Special Needs Programs (D-SNP) that follow the same transparency and interoperability themes. These changes, including the collection of social determinants of health and health equity, are outlined more specifically in a recent blog post by HealthEdge’s Compliance team.
The Bottom Line
Transparency and higher levels of payer interoperability are front and center on the regulatory stage today. With the provider side having been through much of this transformation in the past 10-15 years with the adoption and use of electronic health record (EHR) systems, CMS and the regulators are turning their attention to the administrative side of healthcare claims, zeroing in on opportunities to improve transparency and interoperability.
To learn more about how HealthEdge is supporting its customers’ ability to meet current and future regulatory requirements, please visit www.healthedge.com.