CMS Rule Targets Prior Authorization with Interoperability

Today, the Centers for Medicare & Medicaid Services (CMS) passed a final rule that promotes data sharing, patient access to health information, coordinated care, and interoperability to streamline the prior authorization process.

The rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while reducing provider and patient burden.

The “CMS Interoperability and Prior Authorization” rule will allow certain payers, providers, and patients to have electronic access to pending and active prior authorization decisions. This is expected to cut back on repeated requests for prior authorizations, thereby reducing costs and administrative burden so providers can deliver higher quality care.

“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data.”

“Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization,” Verma continued. “This change will reverberate around the healthcare system for years and decades to come.”

This final rule requires the payers regulated under this rule—Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)—to use application programming interfaces (APIs) that will give providers better access to data and make the process of prior authorization more efficient.

Smartphone applications are based on APIs. When integrated with a provider’s EHR, they can provide convenient data access for patients and providers. This means that providers can have a complete picture of their patients’ care and patients can take their information with them as they move through the healthcare system. This ensures more coordinated care, and less repetitive costly care.

In addition to improving the convenience of health information access, the implementation of APIs will reduce the inefficiencies of the prior authorization process for providers through automation. The final rule will require payers regulated under this rule to maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard.

The CMS rule also intends to improve patient experience as well. For example, when a patient sees that a prior authorization has been submitted, they will better understand the timeline for the process which will allow them to plan accordingly with their provider.