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Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Info

On December 10, the U.S. Centers for Medicare & Medicaid Services (CMS) released new rules relating to patient health exchange, or interoperability, and what that means for providers, patients, and payers within this context. While providers and patients will see reduced burden, payers will now have additional requirements to fulfill.


CMS aims to build on the original ruling, ‘Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Information,’ as part of their initiative to improve health information exchange and reduce patient burden. Taking the original rule, CMS has now expanded it to ensure that payer and provider burden is reduced while still creating more accessible avenues for accessing health information.


The rule would require increased patient electronic access to their health care information and would improve the electronic exchange of health information among payers, providers, and patients.


With these new measures in the mix, payers will likely need to take a long look at current processes, especially relating to prior authorization and its role in patient health information exchange.


Officially titled ‘Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Information,’ we’ll look at the requirements laid out broadly and then examine some of the implications for payers and medical prior authorization in more detail.


Here’s what you need to know about CMS and its requirements around promoting interoperability.



What are the CMS interoperability requirements?


The broad scope of the rule is to improve interoperability and patient access to health information, and this applies to:


Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Information

  • State Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs

  • Medicaid managed care plans.

  • CHIP managed care entities

  • Qualified Health Plan issuers on the federally-facilitated exchanges


More specifically, these specific CMS-regulated payers will need to improve interoperability and electronic healthcare data exchange via Application Program Interfaces (APIs) to streamline prior authorization processes and ensure that patients can access health data easily.


This is particularly important as patients will likely switch in and out of various programs based on eligibility and different requirements. Therefore, they will face medical prior authorization challenges that can cause delays in care. As patients switch between payer types and plans, this rule can help avoid any disruption in care. It protects patient health data and enables it to move with them as patients switch providers and payers.



How do CMS interoperability requirements affect prior authorization?


The main takeaway from this rule? Prior authorization processes need to be smooth, effortless, and timely. Patients should be able to access their health data electronically with ease if they change providers and payers. With that in mind, payers need to look at their current prior authorization processes and their role in health administration burdens.


To comply with the CMS interoperability rule and reduce patient and provider burden, payers will need to implement APIs to facilitate information sharing and exchange between payers and providers and between two payers. A patient access API will also be required to ensure that patients can easily access their data regarding prior authorization processes.


APIs are especially useful in this context because they can connect to other digital tools seamlessly. They can be connected to mobile apps, practice management systems, and provider electronic health records (EHR).


There are 4 APIs proposed under this measure:

  1. Patient Access API: This will include information around any pending and active prior authorization decisions for patients. Having access to this information ensures that patients have more insight into the prior authorization process and its impact on their care.

  2. Provider Access API: Payers must build and maintain APIs for payer-to-provider data sharing of claims and a subset of clinical data, encounter data. The API must also include pending and active prior authorization decisions for both individual patient requests and groups.

  3. Prior Authorization API: To reduce patient burden and provider burnout, the API must include Document Requirement Lookup Service, Prior Authorization Support, Denial Reason, metrics, and shorter prior authorization timeframes overall.

  4. Payer to Payer API: The payer to payer API will need to be enhanced and include Payer-to-Payer Data Exchange at Enrollment, Leveraging information about pending and leveraging active prior authorization decisions during patient transitions,

This creates a better experience for patients overall in various ways. Increased automation reduces the administrative burden involved in medical prior authorization and goes a long way in improving care coordination.


The proposed rule and its new requirements also entail the adoption of specified implementation guides potentially. This would help payers establish APIs quickly and standardize the process to an extent, reducing the risk of disruption in patient access to health records.


With an increasing dependence on technology, there is a growing need to ensure that inoperability remains a central requirement when considering the patient experience. Data exchange and access are critical elements of the healthcare system as it relates to patients.


Without it, healthcare administrative processes can take up far more time needed. Without timely medical prior authorization, patients face far more risks when it comes to continuity of care.


However, through an efficient and modern prior authorization process, payers can ensure that interoperability continues and create a better patient experience overall. Banjo Health’s Virtuoso AI is a comprehensive prior authorization microservice that streamlines the process and is designed by clinicians for clinicians and streamlines.


Combined with Harmony, a comprehensive PA management platform, providers can access integrated hospital and provider data and manage the PA process from end-to-end so that interoperability can remain a priority. Contact us today to learn more!


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