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Episode 162: Workgroup Voices, The Inner Workings of Prior Authorization

June 22, 2022

Written by Charles Stellar, WEDI President & CEO

As we know all too well, the health care standards and operating rules development process can be highly siloed. However, this mold was cast aside by the three Standards Development Organizations, Health Level Seven (HL7), the National Council of Prescription Drug Programs (NCPDP), X12, along with the CAQH Committee on Operating Rules for Information Exchange (CORE) and WEDI. These organizations have come together in an unprecedented effort to exhibit unanimity on key administrative transactions development and implementation issues.

As part of this cooperative effort, the group penned a joint letter in direct response to the National Committee on Vital and Health Statistics (NCVHS) March 30, 2022, letter to the Department of Health and Human Services (HHS) where the federal advisory body issued recommendations to modernize aspects of HIPAA and other HIT standards with the goal of improving patient care and reducing industry burden.

In the group’s response to HHS on the NCVHS recommendations, the organizations worked together to develop common recommendations and context to share with HHS. Given their unique leadership roles within this industry space, this effort is especially powerful. The comments fell into three main categories:

  1. Support for expedited issuance of regulation establishing a standardized approach to electronic attachments. Here the group strongly urged HHS to expedite issuance of a regulation establishing a standardized approach to electronic attachments.
  2. Prioritization of a predictable federal process and guidelines for demonstrating value of adoption. The group, for example, encouraged HHS to prioritize a predictable federal process and guidelines for demonstrating value of adoption and urged that regulations be issued without undue delay for those standards and operating rules with widespread industry support. The group also pledged to work with HHS in development of this more nimble and responsive approach to standards adoption.
  3. Opportunities to streamline HIPAA process for ease of implementation and effectiveness of standards. The group recommended HHS adopt the process of “failing fast” and establish a process of earlier evaluation of effectiveness using clear criteria that results in more timely industry advancement. Further, the group contended that with clear guidelines and criteria to measure impact and a simplified process, the industry may be more willing to engage in the HIPAA exceptions process.

While I am excited that this collective effort culminated into a set of recommendations to the government, I am more excited about future opportunities for this collaborative. Working together, CAQH CORE, HL7, NCPDP, X12 and WEDI have the ability to collectively shape the future of standards and operating rules and drive our industry forward.

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