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TWO PROVISIONS TO WATCH IN THE CMS PRIOR AUTHORIZATION RULE

CMS IS LEVERAGING PRIOR AUTHORIZATION TRANSACTIONS TO IMPROVE INTEROPERABILITY


The recent CMS prior authorization and interoperability proposed rule is an
important step to improve data exchange and transparency between health plans,
providers, and patients.

The current regulatory approach to promote health information digitization began
with The Health Information Technology for Economic and Clinical Health (HITECH)
Act of 2009, which directed the Office of the National Coordinator for Health
Information Technology (ONC) to promote the adoption and meaningful use of
electronic health record (EHR). Five years later, 97% of non-federal acute care
hospitals were utilizing a certified EHR system, all the more significant
considering less than 10% possessed a basic EHR system in 2008. However, the
widespread adoption of these systems was just the first step in improving
interoperability. Remaining challenges include:

 * Lack of a standardized application programming interface (API)
 * Fragmented health information exchanges (HIEs)
 * Minimal incentive for data exchange between healthcare stakeholders

Prior authorizations are one example of transactions that require information
exchange between health plans, multiple providers and practices, and patients.
By regulating improvements in key areas, CMS can introduce solutions to discrete
challenges that will improve interoperability more broadly. Two provisions of
the CMS Prior Authorization rule to watch are:

 * Health plans must build and maintain a Fast Healthcare Interoperability
   Resources (FHIR) API (PARDD API) that automates the process for providers to
   determine prior authorization requirements, documentation, and decision
   guidelines. The API aims to reduce providers’ prior authorization burden and
   ensure patients, providers, and health plans can all access the appropriate
   information to make informed, efficient care decisions.
 * Health plans must also include a specific reason when denying a prior
   authorization request to facilitate better communication and understanding
   between the payer and provider and, if necessary, a successful resubmission
   of the authorization request. 
   

To comply with these CMS interoperability standards by the January 2026
implementation deadline, health plans can implement intelligent prior
authorization. These solutions automate and streamline manual prior
authorization processes, but go a step further and bring longitudinal context to
individual prior authorization transactions. Intelligent prior authorization
results in higher quality patient care, delivered more efficiently and
cost-effectively. Sophisticated health plans use artificial intelligence and
machine learning to leverage the wealth of data collected from patient profiles,
prior authorization transactions, and claims data. By adding regulations to
streamline all of this data and ensure its protected exchange between
stakeholders, CMS is taking the first steps to improving care quality for
patients.

Some incremental provisions to help with the broader implementation guidelines
are outlined in the CMS Medicare Advantage and Part D Final Rule, which includes
interoperability and transparency provisions like requiring plans to post
coverage criteria used to make medical necessity decisions and requiring that
Medicare Advantage plans must comply with national coverage determinations,
local coverage determinations, and general coverage and benefit conditions
included in Traditional Medicare regulations. Compliance with this new rule by
its implementation deadline of January 2024 will also help drive incentive and
momentum for the larger CMS prior authorization rule. Health plans should begin
strategizing for compliance now to achieve full-scale implementation by the
required deadlines.

Is your health plan already using AI and ML or trying to catch up with these
federal regulations? Learn how to do more (or get started) with intelligent
prior authorization solutions, which solve interoperability and transparency
challenges, in this article.

Published On: June 26th, 2023Categories: Blog, Compliance 101

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ABOUT THE AUTHOR: JASON AMARAL

Jason Amaral serves as Engineering Operations Manager at Cohere Health, leading
IT strategy for health information exchange. Jason has a strong background in
the healthcare information technology industry and held previous project
management and data integration positions at athenahealth and MEDITECH. Jason
earned his BBA from the Isenberg School of Management at the University of
Massachusetts at Amherst, with a focus in marketing and healthcare policy. He is
currently working toward his MBA from Boston University.
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Boston, MA 02114
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