The CMS Interoperability Rule: Mastering Patient Access APIs

by David Finney, Partner & Co-Founder, Leap Orbit

Struggling to navigate the complexities of the CMS Interoperability Rule? You’re not alone.

The CMS Interoperability Rule

The Centers for Medicare & Medicaid Services (CMS) issued the CMS Interoperability and Prior Authorization Final Rule (Final Rule) on Jan. 17, 2024. The Final Rule focuses on improving prior authorization processes and access to interoperable patient data (by patients, providers, and payers).

The Final Rule applies to:

• Medicare Advantage (MA) organizations
• Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs
• CHIP managed care entities
• State Medicaid and Medicaid managed care plans
• Qualified Health Plan (QHP) issuers on the federally facilitated exchanges (FFEs) (collectively, Payers)

The May 2020 CMS Interoperability and Patient Access rule established a technological foundation on which the Final Rule was built, requiring payers to implement an HL7® FHIR® Patient Access API. Under the Final Rule, payers are required to add information about prior authorizations (excluding prescription drugs) to the data available via the Patient Access API. It also expands the Merit-based Incentive Payment System (MIPS) to increase the adoption of electronic processes.

Concerns with Patient Access to Interoperable Data

No doubt the patient access component is most daunting, with 64% of payers indicating in a readiness survey that this is their biggest concern. Making sensitive patient data available via API is a significant technical challenge, even for many larger organizations. Complexities associated with consent management and privacy and security must be navigated. The risk profile of launching such a service is very high.

With this in mind, it’s understandable that many plans picked a technology vendor with expertise in patient access as their one-stop-shop for a solution to the entire Interoperability Rule. Many of those vendors are offering to throw in a provider directory API solution as a bonus. But there’s peril for plans following this path of least resistance — and many of them are starting to feel it now. Look no further than other regulatory action, including the federal No Surprises Act, for proof that implementing the provider directory API should be a strategic investment more than an afterthought.

Cloud-Native Provider Data Management

There is a way for your health plan to future-proof your provider data operation, and it’s not too late to switch in a painless, cost-effective way. Just like Salesforce and Google have revolutionized other sectors with cloud-native data management platforms, a good provider data management platforms can be deployed and configured in a matter of days, dramatically shortening a customer’s time to value. Choosing such a platform also eliminates much of the execution risk inherent in the implementation of custom enterprise software.

The Convergent Provider Data Hub bridges the gaps in fragmented, poor-quality provider listings across institutions, systems of care, and technology platforms. This data-as-a-service solution uses proprietary matching and cleansing algorithms to sift through and unify provider data from large public and proprietary data sets. The fully FHIR 4.0 compliant suite of APIs and mobile-friendly user interface provide health plans and Medicaid agencies with clean, curated, and always up-to-date network data.