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Knowledge Center

Episode 158: Slow and Steady, How Health Care is Progressing Toward Value Based Care. Lynn Carroll, HSBlox

January 4, 2023

Written by Robert Tennant, Vice President Federal Affairs

The Centers for Medicare & Medicaid Services (CMS) has released two long-awaited proposed rules that will significantly impact the health care industry. December 13 saw the release of the “Advancing Interoperability and Improving Prior Authorization Processes” Notice of Proposed Rulemaking (NPRM), followed about a week later with the publication of “Adoption of Standards for Health Care Attachments

Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standard” NPRM. Combined, these two proposals have the potential of transforming how providers and payers exchange information.

With the Prior Authorization rule, CMS is seeking to improve patient and provider access to health information and streamline prior authorization processes. The rule includes proposals requiring Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children’s Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchange to implement Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standard Application Programming Interface (API) to support electronic prior authorization. The Agency also proposes requiring covered payers to include a specific reason when denying requests, publicly report certain prior authorization metrics, and send authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent). CMS also proposes to add in the future a new Electronic Prior Authorization measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category.

The electronic attachments rule, as proposed, would adopt standards to support both claims and prior authorization transactions, as well as adopt a standard for electronic signatures to be used in conjunction with health care attachments. CMS also proposes to move from Version 5010 to Version 6020 for the standard referral certification and authorization transaction (X12 278). We were very pleased to see WEDI referenced several times in the proposed rule, including the Agency citing a joint WEDI, HL7, and X12 white paper from November 2017, and acknowledging that it has taken the paper’s contents “into account in [the] proposed rule.” As well, WEDI contributions were recognized in the cost-benefit analysis section of the rule.

Opportunities for Member Input

One of the strengths of WEDI is our ability to convene the industry, effectively solicit perspectives from our multi-stakeholder membership, and submit to the government a consensus-based set of comments and recommendations. To respond to these important rules, WEDI will be implementing our recently revised Member Position Advisory (MPA) process.

This MPA process will include:

  • Surveying the industry on the key provisions in each of the NPRMs;
  • Discussing these provisions and related implementation issues in both the WEDI Prior Authorization and Attachments Subworkgroups; and
  • Conducting live virtual events to develop consensus positions on both the Prior Authorization and Attachments rules.

Take advantage of each of these opportunities to share your perspectives on these important regulations. As a WEDI organizational member, all of your colleagues are WEDI members and can participate in MPA activities. We look forward to hearing from our members and developing comprehensive responses to both proposals.

Both proposed rules will significantly alter how providers and health plans transmit and receive health information. It will be critical for the industry to coalesce around a consistent message to ensure the final rules will be beneficial to providers, payers, and the patients they serve.

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