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3 Ways New Interoperability Regulations Will Impact Payer-Provider Collaboration


With April’s passage of Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Patient Access Final Rule, healthcare organizations are required to improve interoperability, reduce barriers to data exchange, eliminate “information blocking” and standardize notification practices. Under terms of the Office of the National Coordinator for Health Information Technology (ONC) rule, healthcare organizations must adopt the HL7 Fast Healthcare Interoperability Resources (FHIR) standard for application program interfaces (APIs).

To be enforced starting July 1, this rule is expected to impact all players in the healthcare industry by bringing all stakeholders up to speed. The point is to ensure organizations can communicate easily and effectively, and that patients will have unbridled, yet secure, access to their own health information via their preferred device.

While news outlets have highlighted the impact on healthcare providers and patients, the rule poses major implications for payers, too.

As America’s Health Insurance Plans (AHIP) noted recently in an industry brief, payers will need “the ability to gather and share data on provider payer amounts, patient cost-sharing information, clinical data points, and more.”

This call to action has raised questions around compliance: Will payers have to invest in new technology to comply with the Final Rule’s specific provisions? And how will the rule shape future collaboration and communication between payers and healthcare providers?

Here are three key considerations for payers as they navigate and adapt to the new rules:

#1: Technology and data
As writer Jared Kaltwasser noted in a recent article for Managed Healthcare Executive, “No industry better straddles the dichotomy between cutting-edge technology and inefficient obsolete devices than the healthcare industry.”

An example: Clinicians using fax machines to send patient data, while physicians a few doors down use advanced diagnostic imaging tools to pinpoint a miniscule tumor embedded in dense tissue.

While interoperability rules were crafted to end this dichotomy by creating a universal technology standard, health plans must still consider the magnitude of historical data they’ll need to account for when making system upgrades. According to AHIP, the scope of data to be shared by health insurance providers “is extensive, including provider payment amounts, patient cost-sharing, clinical data, formularies, and provider directory information.”

#2: Patient communications
Health plan members value clear, transparent communications, and the changes to information sharing connected to the Interoperability Rule should be communicated as clearly (and early) as possible. AHIP’s guidance notes that health insurance enrollees must be “proactively advised” that they are not required to use only the health insurance provider’s own preferred applications. Also, health plans should be thoughtful about sharing information in a “user friendly” format void of clunky language that’s difficult for the average member to comprehend.

#3: Cost planning:
With so many potential technology upgrades and policy changes in the pipeline for the second half of 2021, it goes without saying that health plans will need to allocate financial resources around compliance activities (e.g., system upgrades). But that doesn’t mean payers can’t be smart about how they use their budgets to elevate information sharing, achieve compliance, and, ultimately, improve communication and collaboration with their members and providers.

According to AHIP, while the CMS rule precludes health insurance providers from charging patients for using apps to access information, it acknowledges that the increased costs associated with maintaining the technology may be incorporated in bids.

Moving forward, health plans should consider whether their vendor partners — as well as the technology platforms and networks they utilize to share clinical and financial data — align with new regulations. As regulators continue to release new guidance, AHIP advises healthcare organizations to pay close attention to additional rules extending to new use cases.

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