Chasing the marathon goal of patient centricity, CMS has sprung into action, yet again. While some may laud this as the victory lap, payers may not be amused, at least in the ‘short run’. Every noble quest has a price to be paid, and so does this one. Payers may find themselves footing the bill for the massive array of changes required. Those failing to do so might have to take a pit stop for the CMS regulated health plans.

Here is a snapshot of changes to be made for the Interoperability and Patient Access rule.

What Does the Regulation Mandate?

It is obvious that interoperability is essential, and the technical challenges around it are the ones that pose as roadblocks, as you pave the way for a smooth and efficient data flow and exchange. Below are a few requirements that Health Plans would need to fulfil, should they choose to participate in CMS programs.

Patient Access API that can be used by 3rd party developers
  • Applicable to Medicare Advantage (MA), Medicaid and CHIP – FFS and managed care, health insurance Exchanges established under the ACA and Federally run QHPs
  • Data Scope Clinical data maintained, Claims, Remittances, Encounters, Formularies or preferred drug lists. All of that, with DoS from 1st Jan 2016
  • Standard USCDI and FHIR
  • Reflex time Claims/Clinical data within 1 business day of adjudication/ receipt of encounter data
  • Timeline By July 2021
Provider Directory API to be accessible via digital endpoint on payer website, for discovery/access
  • Applicable to MA, Medicaid and CHIP – FFS and managed care
  • Data Scope – At least, Provider name, address, phone numbers, and specialty. For MA plans covering part D, pharmacy name, address, phone number, number of pharmacies in the network, and mix
  • Standard – USCDI and FHIR
  • Reflex time – Within 30 days of a change to the provider directory
  • Timeline – By July 2021
Payer to Payer data exchange to allow patients to port their information when switching payers
  • Applicable to MA, Medicaid and CHIP managed care entities and QHPs on Federally facilitated exchanges. Medicaid and CHIP state agencies not covered
  • Data Scope – Data set covered under USCDI, including data going back up to 5 years - data maintained with a DoS from 1st Jan 2016
  • Standard – USCDI
  • Timeline – Jan 1st 2022

What Needs to be Done?

While opening the APIs is the stated requirement, HIPAA compliance is an implicit one. Given the potentially massive effect this incoming traffic can have, the changes demand a well-thought-out, standard-based, secure, extensible and scalable technical infrastructure.

To ensure that you future-proof the required infrastructure, below are vital elements your solution must-have.

Aggregate data across silos and map it with USCDI

Implement one gateway for secure handling of requests

Implement interoperability using FHIR V4

Centralized and Extensible for Authentication/Authorization

Traceable automation of the entire request-response loop

What are the Challenges that Await?

Most health plans have systems that are reliable and can handle volumes of data pretty well. Unfortunately, the latter affects the former when a change and responsiveness is in question. Both these factors might make this an exciting quest. Below are a few others.

Aggregating data spanning multiple systems to fulfil a request

Deciphering interoperability standards (FHIR, USCDI) and associated pitfalls

Security, audit and automation considerations for straight-through processing

How Can We Help You in this Journey?

We have been working with interoperability standards such as FHIR for long enough, that we can help you embrace FHIR/USCDI and all that goes with it, to be compliant and practically usable!

Assessment of your
technology landscape

Custom solutions development
to suit your individual context

Technical approach and
design presentation

Agile and phased
implementation – Parallel Tracks

UAT, Go
Live and metering

Let’s FHIR it up!

Let’s understand your context and offer potential solution(s) over a quick call.

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