What the Interoperability Rule Will Mean for Payers in 2021

Background of the interoperability rule

CMS finalized the interoperability rule in March 2020. The rule is part of the cross-agency MyHealthEData initiative started in 2018 to facilitate data-sharing across public payers and provider organizations.

The finalized rule requires payers to provide a Patient Access application programming interface (API) which gives patients access to certain health data including personal data in accordance with the ONC 21st Century Cures Act final rule. Also, payers must offer a Provider Directory API, which clearly delineates which providers are in-network.

However, CMS recognized that payers would have difficulty meeting the original deadline due to the disruption of the coronavirus pandemic.

The agency had originally given payers until January 2, 2021 to comply with the new interoperability standards for both the Patient Access API and the Provider Directory API, but has since extended the deadline to July 1, 2021.

“These actions follow the extensive steps CMS has taken to ease the burden on the healthcare industry as it fights COVID-19,” CMS Administrator Seema Verma said at the time.

The implications for payers in 2021

The CMS final rule applies to most public payer entities across Medicare, Medicaid, and Children’s Health Insurance Plans (CHIP).

The exceptions are Medicare cost plans, stand-alone prescription drug plans, and Program of All-Inclusive Care for the Elderly (PACE) organizations as well as certain plans on the federally facilitated exchanges—namely stand-alone dental plans and small business health options program exchanges.

AHIP enumerated several ways that the interoperability rule will impact payers’ procedures.

Eligible payers will need to be able to gather and share data on provider payer amounts, patient cost-sharing information, clinical data points, and more.

Importantly, payers cannot require members to use payer apps. Web-based technology will be in competition with third-party vendors and members can select what they use.

Members must be educated about how to ensure that apps protect patient privacy. The American Academy of Neurology has alerted CMS to the need for a security framework for these apps to ensure better security. There should be regulation around the responsibility for APIs to protect patient data, the organization said.

At the moment the burden of informing patients about a third-party vendor’s security or lack thereof falls on payers and providers. However, payers cannot reject sending data to a patient’s preferred, secure vendor app.

Payers may not charge vendors for their services. However, vendor-related costs can be covered in payer bids.

Information blocking—the practice of in any way preventing easy patient data access or transfer or use of patient data—is forbidden.

CMS has outlined technical standards for both APIs.

Payers will not have to get certified through the ONC’s Certified Health IT process, but the standards CMS set for these APIs are very similar to these certification requirements.

Future developments related to the interoperability rule

Payer-to-payer data transfer technology is also included in the finalized rule, but does not need to go into effect until January 2022. CMS did not provide technical standard details for this part of the rule. There will need to be a national framework in place for payers to share data.

Other elements of the rule remain open-ended and AHIP said it expects to see these finalized in the coming months.

For example, a provider’s capacity to download patient population data from a third-party app in a timely, accurate way will have to be tested.

CMS will also need to offer greater specificity around API price transparency. Also, AHIP said it anticipates that the agency will need to allow for documentation requirement lookup service which facilitates real-time feedback for providers regarding payer prior authorization and documentation requirements on a particular clinical service.

AHIP said it anticipates that the additional information will be published in fall of 2020.