The CMS Interoperability and Patient Access Final Rule is a regulation that aims to promote greater interoperability, patient access, and innovation in the healthcare industry, while also improving the quality and cost-effectiveness of care. The rule was issued by the Centers for Medicare & Medicaid Services (CMS) in May 2020 and focuses on promoting interoperability and patient access to health information for beneficiaries of Medicare Advantage, Medicaid, and the Children’s Health Insurance Program (CHIP).

The rule requires health plans to share claims data, clinical data, and other types of health information with patients and other healthcare providers in a standardized, secure, and timely manner. It aims to improve care coordination among healthcare providers by making it easier to exchange patient health information securely and in a timely manner. The rule also requires health plans to make patient health information available through APIs, enabling patients to access their health information through mobile applications or other third-party tools.

Promote the interoperability of health IT systems

The CMS Interoperability Rule seeks to advance patient access, interoperability, and innovation in the healthcare sector while simultaneously raising standards of care and lowering costs. There are five significant provisions in this.

• Patient access to health information: Health plans must comply with the rule and provide patient health information via APIs. Through mobile apps or other third-party resources, patients will have access to their medical records.
• Access to Prior Authorization: In order to help patients stay at the center of their own care and receive the necessary medical attention in minutes rather than days, the rule focuses on efforts to enhance prior authorization procedures.
• Health information sharing: According to the rule, health plans must use APIs to exchange specific categories of health information with patients and other health plans, including encounter and claims data.
• Boost the coordination of care: By facilitating the safe and prompt exchange of patient health information, the rule seeks to enhance care coordination between healthcare providers.
• Reduce healthcare costs : The rule aims to reduce healthcare costs by promoting competition among healthcare providers and enabling patients to make more informed decisions about their healthcare.

Important interoperability policies

The CMS Interoperability Rule consists of several interoperability policies, including:

• API for Patient Access: A standards-based API is required by Medicare Advantage, Medicaid, and CHIP plans to give their beneficiaries access to their claims and encounter data. This policy is known as the Patient Access API. Beneficiaries can use the API to view and share their health data with any third-party applications they choose.
• API for Provider Access: In order to share patient data with in-network providers with whom the patient has a treatment relationship, payers are required by the Provider Access API to create and maintain a Provider Access API. Using FHIR standards, the Provider Access API enables third-party software applications to connect to and retrieve data from an EHR system.
• Documentation, Decision, and Prior Authorization Requirements (PARDD) API: This policy mandates that prior authorization requests and decisions for Medicaid, CHIP, and some private health plans must be made electronically and that providers and patients must have access to a standards-based API for submitting and receiving prior authorization requests and decisions.
• API for Provider Directory: Medicare Advantage, Medicaid, and CHIP plans are required by the Provider Directory API policy to provide provider directory information via a standards-based API. Beneficiaries can locate and choose healthcare providers using the API according to factors like specialty, location, and other specifications.
• Payer-to-Payer Information Sharing: Medicare Advantage, Medicaid, and CHIP plans are required by the Payer-to-Payer Data Exchange policy to share specific health information with other plans at the beneficiary’s request, including encounter and claim data. The goal of the policy is to support beneficiaries who transfer health plans in terms of care coordination and continuity.

The challenges for Medicare Advantage, Medicaid, and the Children’s Health Insurance Program (CHIP)

• Observe CMS rule’s interoperability guidelines.: Health plans may find it difficult to meet the deadlines for complying with the interoperability policies set forth in the CMS rule due to the intricate technical and operational requirements. There may be fines and other repercussions for breaking the rule.
• Resources, excessive expenses, and ignorance: Advanced health IT systems and data standards are needed to implement the interoperability policies in the CMS rule. Additionally, they demand a large amount of staff time and financial resources, which could be difficult for smaller healthcare organizations and providers.
• Collaboration and coordination: Health plans, healthcare providers, and patients must coordinate and work together to implement the interoperability policies outlined in the CMS rule. In order to guarantee that the policies are carried out efficiently and that the advantages of increased interoperability are experienced, health plans need to interact with these parties.

In conclusion, the CMS Interoperability and Patient Access Final Rule is a significant step toward improving the healthcare industry by promoting interoperability, patient access, and innovation. The rule aims to improve care coordination among healthcare providers, reduce healthcare costs, and enable patients to make more informed decisions about their healthcare. By giving patients access to their health information, the rule puts patients first and helps to ensure that they receive the care they need when they need it.