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.