Interoperability in healthcare

CMS Proposes”CMS-0057-P” to Streamline Prior Authorizations with Real-Time Approvals Using Interoperability in Healthcare


December 21, 2022 | Reading Time: 3 Minutes

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What Is Interoperability in Healthcare?

The ability of different systems, devices, and applications to work together and exchange information seamlessly is known as interoperability in healthcare. At its best, it would allow patients using multiple insurance plans (e.g., Medicare and a supplemental plan) to receive care from multiple providers (e.g., primary care physician, psychotherapist, physical therapist, pharmacist) who work in multiple healthcare systems. Interoperability is essential in healthcare because it allows providers to access and use relevant patient information from different sources, such as electronic health records (EHRs), lab results, psychological testing, and radiology images. Interoperability can help improve patient care by offering providers a more complete and up-to-date view of a patient’s health status and history. In this article, the recent proposal identified as “CMS-0057-P” by the Centers for Medicare and Medicaid Services (CMS) for the concept of interoperability will be applied to the prior authorization process.

CMS-0057-P Proposal to Improve the Prior Authorization Process

As healthcare organizations strive for improved patient outcomes and operational efficiencies, interoperability and prior authorization processes have become increasingly important topics of discussion. In an effort to address these issues, the Centers for Medicare and Medicaid Services (CMS) has released a proposed rule, CMS-0057-P, which aims to advance interoperability and improve prior authorization processes. This fact sheet aims to summarize the key points of the proposed rule and its potential impact on the healthcare industry.

The proposed rule is a comprehensive approach to addressing the challenges that healthcare organizations face with regard to interoperability and prior authorization processes. The proposed rule aims to improve the exchange of electronic health information between healthcare providers, payers, and other stakeholders and to streamline the prior authorization process for services and procedures. By implementing these changes, CMS aims to reduce administrative burdens on healthcare providers and improve the overall quality of care for patients.

CMS Calls for FHIR Adoption to Enhance Interoperability in Healthcare IT

One of the main goals of the proposed rule is to improve interoperability between electronic health record (EHR) systems and other health information technology (HIT) systems. To achieve this, CMS proposes adopting the Fast Healthcare Interoperability Resources (FHIR) standard for electronic health information exchange. FHIR is a widely adopted standard that allows for easy data exchange between different HIT systems. Its adoption could help reduce the need for manual data entry and improve the accuracy of patient records.

The proposed rule also includes five RFIs. These RFIs seek input from stakeholders on various topics, including the potential benefits and challenges of implementing the proposed rule and any potential unintended consequences.

Streamlining Interoperability & Prior Authorization Processes With Real-Time Approvals

In addition to improving interoperability, the proposed rule also aims to streamline prior authorization processes. Prior authorization is a process by which healthcare providers must obtain approval from payers before providing certain medical services or prescriptions. This process can be time-consuming and burdensome for providers, leading to delays in patient care.

To address these issues, CMS proposes adopting several measures to streamline the prior authorization process. These measures include:

  • Implementing real-time prior authorization: This would allow providers to receive approval for certain services in real time rather than waiting for a response from the payer.
  • Expanding the use of electronic prior authorization: By encouraging the use of electronic prior authorization systems, CMS hopes to reduce the burden on providers and improve the efficiency of the process.
  • Improving the transparency of prior authorization requirements: CMS proposes requiring payers to clearly communicate their prior authorization requirements to providers to reduce confusion and improve the accuracy of prior authorization requests.

In addition to these provisions, the proposed rule includes several other measures designed to improve interoperability and streamline prior authorization processes. For example, it includes provisions for the use of application programming interfaces (APIs) to facilitate the exchange of health information and measures to encourage the development of new technologies and approaches to interoperability.

Overall, the CMS-0057-P proposed rule represents an important step towards improving interoperability and streamlining prior authorization processes in the healthcare industry. By adopting the FHIR standard and implementing other measures to improve efficiency, CMS hopes to reduce the burden on providers and improve the quality of care for patients.

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