Interoperability in 2024: 3 key updates for payers

CMS INTEROPERABILITY AND PRIOR AUTHORIZATION FINAL RULE

This long-awaited rule finalized by the Centers for Medicare & Medicaid Services (CMS) in January requires Medicare Advantage plans, Medicaid plans, and other federally funded payers to implement FHIR-based application programming interfaces (APIs) to improve the electronic exchange of health care data while also expediting prior authorization processes. These APIs must support payer-to-payer access, provider access, direct patient access, and prior authorization, with a deadline of January 1, 2027.

 What it means for payers: The clock is ticking for payers covered by this rule. Payers will now have to communicate the approval or denial of a prior authorization request, or the request for more information. Information about prior authorizations must be included in the data available via the patient access API. In addition, payers will be required to share patient claims and encounter data with in-network providers with whom the patient has a treatment relationship. This same information must be shared for improved continuity of care when a patient changes health plans.

ONBOARDING OF QHINS AND RELEASE OF COMMON AGREEMENT V2

Five Qualified Health Information Networks (QHINs) have now completed the TEFCA onboarding process and can now support FHIR-based data exchange under the Common Agreement, version 2 of which was released in January. Until this point, there was ambiguity regarding the timelines to support exchange purposes outside of treatment and public health, which made it difficult for payers and their business associates to plan their interoperability strategies around use cases such as payment integrity, quality improvement, and risk adjustment. However, version 2 provides a carve-out for payers and their delegates to participate in QHIN data exchange.

What it means for payers: By joining a QHIN, payers and their health care analytics partners like Cotiviti can dramatically improve the amount of digital information acquired through a single point connection. Instead of contracting with a patchwork of providers individually and dealing with proprietary formats, payers can now access high-quality clinical data at scale.

ONE INFORMATION BLOCKING RULE FINALIZED, ANOTHER PROPOSED

In mid-2023, the Office of Inspector General (OIG) published its final information blocking rule, implementing a $1 million penalty per violation for entities that commit information blocking, which is defined as practices are “likely to interfere with the access, exchange, or use of electronic health information (EHI), except as required by law or specified in an information blocking exception.” This applies to health IT developers as well as health information exchanges. The Department of Health and Human Services (HHS) followed this with a proposed rule to establish disincentives that would apply to providers and health systems.

What it means for payers: As noted by guidance from the American Medical Association, providers who block payers from seeking EHI to confirm a clinical value could be at high risk of committing an information blocking violation. The implementation of these information blocking rules is a highly promising development that could reduce the abrasion that can result from payers seeking medical records to support their payment integrity, risk adjustment, and quality improvement programs.

KEY TAKEAWAYS FOR PAYERS

As additional rules are finalized and timelines emerge, payers should consider these steps to position themselves for interoperability success in 2024.

• Assess your infrastructure: Health plans need to have a scalable infrastructure that includes the API technology needed to send and retrieve data via FHIR resources.
• Read up on TEFCA: As the Recognized Coordinating Entity (RCE) for TEFCA, The Sequoia Project has excellent resources to help payers better understand their role in supporting interoperability. For payers, it is important to read SOP: Health Care Operations (HCO) SubXP-1 to better understand the newly supported exchange purposes and delegate carve-out.
• Join a QHIN: In the spirit of true interoperability, payers have the option of listing their organization in the directory at no cost and using a delegate, like Cotiviti, to handle the technology and query on their behalf—instead of onboarding directly. This will reduce dependencies on copy services vendors and help ensure accurate, high-quality information can be obtained.

To learn more on the future of interoperability and building a successful digital strategy for 2024 and beyond, register for Cotiviti’s upcoming RISE webinar on Thursday, February 29.