Who will be impacted by the CMS Interoperability and Prior Auth Final Rule?
The CMS Interoperability and Prior Authorization Final Rule published in February 2024 significantly impacts various stakeholders in the healthcare system, particularly payers and providers. The rule aims to streamline prior authorization processes and enhance interoperability, building on the framework established in the 2020 Interoperability and Patient Access Final Rule.
Affected Payers
The following categories of payers are directly affected by this rule:
- Medicare Advantage organizations
- Medicaid managed care plans
- State Medicaid fee-for-service agencies
- Children’s Health Insurance Program (CHIP) agencies
- Managed care organizations
- Prepaid inpatient health plans
- Prepaid ambulatory health plans
- CHIP managed care entities
- Issuers of Qualified Health Plans (QHPs) on the federally facilitated exchanges.
These Payers are required to implement new application programming interfaces (APIs) for prior authorization processes by January 1, 2027, with certain metrics reporting obligations beginning in 2026.
Affected Providers
The rule also impacts healthcare providers, specifically:
- Merit-Based Incentive Payment System (MIPS) eligible clinicians
- Eligible hospitals and critical access hospitals in the Medicare program.
These providers will need to adopt electronic prior authorization processes and will be subject to new measures under MIPS to incentivize their compliance with the updated requirements.
Overall, the Final Rule is designed to reduce administrative burdens on both payers and providers while improving patient access to necessary healthcare services.
The new interoperability rule significantly enhances patient access to their health data, fundamentally transforming how individuals interact with their healthcare information. This rule, part of the broader Interoperability and Patient Access framework established by CMS, aims to empower patients by ensuring they have timely and secure access to their health records.
Key Impacts on Patient Data Access
- Immediate Access to Health Information: Patients can access adjudicated claims, provider encounters, and clinical data within one business day after these events occur. This rapid availability allows patients to stay informed about their healthcare status and treatment history.
- Use of Application Programming Interfaces (APIs): The rule mandates that payers implement patient access APIs that enable individuals to retrieve their health information through mobile applications or other digital platforms. This is designed to make data sharing more user-friendly and accessible, aligning with modern technology standards.
- Expanded Data Sharing: As of January 1, 2027, payers will also need to provide prior authorization (PA) data through the Patient Access API. This will inform patients about their plan's PA processes and the status of their requests, further enhancing transparency in healthcare operations.
- Payer-to-Payer Data Exchange: The rule facilitates the exchange of patient data between different payers when a patient opts in, allowing for a more comprehensive view of a patient's health history. This includes sharing up to five years' worth of claims and clinical data, which is particularly beneficial for patients who switch insurance plans.
- Focus on Privacy and Security: While enhancing access, the rule emphasizes protecting patient privacy. Payers are required to ensure that data sharing complies with security standards, thereby safeguarding sensitive health information during transmission.
- Annual Reporting Requirements: Payers must report metrics on the usage of Patient Access APIs starting January 1, 2026. This accountability measure aims to ensure compliance and improve the overall effectiveness of the interoperability initiatives.
In summary, the new interoperability rule significantly improves patient access to health information by promoting timely data availability, leveraging technology for ease of access, and ensuring robust privacy protections. This shift not only enhances patient engagement but also supports better healthcare outcomes through informed decision-making.
Physician CEO Innovator focused on 10x impact | Inspiring Thought Leader | Author and Speaker | TEDx | "AI in Clinical Medicine" book (published by Wiley)
1wI remember the very paternalistic discussions on the dangers of having patients access their own information, fears that have not materialized and there are so many benefits: better information access, more empowerment and agency … great to see!