In 2021 SMILE was chosen as the number-one Vendor by payers to support their implementation of the CMS interoperability and patient access final rule

Are you a U.S. Payer? Check out this video featuring?Eric Rutledge MD that talks about the CMS 0057F rule and what payers need to do today.

The CMS 0057F Rule and What Payers Need To Do Today!

https://www.youtube.com/watch?v=ePArlK1c4d4

Here is the transcript

I'm Eric Rutledge the healthcare regulation

specialist at Smile Digital Health my

background includes an MD degree with

Pathology residency computational

biology and clinical informatics

historically I've been the person that

sits on the provider's side who has a

calendar full of weekly and monthly

reminders to run reports M map incoming

data collate that data and send it over

sepal interfaces so I've experienced the

painful process of making data

interoperable the analog way in this

video we're going to break down aspects

of the CMS interop rule 0057 F or 57f it

was finalized in January and we're going

to explore what the true Roi opportunity

for payers is now we are at a time where

automations can relieve a lot of these

burdens in healthcare and that's why I'm

excited about this video watch into the

end and you'll learn what this means

what this rule means for payers

organizations how it impacts the health

ecosystem four things you need to

consider and what your next steps are

the Caps are the best Market Advantage

let's dive in first a quick look at what

the rule itself includes the CMS interop

rule 57f requires that payers maintain

five apis provider directory API and

patient access API are from the previous

CMS

9115f patient interoperability or

interoperability and patient access rule

the provider directory API stays the

same patient access API is some

reporting requirements in 2026 and API

updates to include prior authorization

statuses by January 1st 2027 the third

is payer to payer which was withdrawn

from the original or from the 9115f but

is now finalized in 57f as a member

directed bulk fire exchange that must

include claims and clinical data going

back five years this is due January 1st

2027 as well the fourth is provider AIS

which uses similar Machinery bulk fire

exchange but it's designed for

bidirectional changed between providers

and payers and finally the prior off API

has complex reporting requirements in

2026 and an API due January 1st

2027 now before we get into this rule

further let's look at the purpose of CMS

57f this will help us inform business

decisions that payers need to make

regarding this rule so let's zoom out to

the concept of Health

Equity now ultimately CMS and onc are

working in tandem to improve Health

Equity by imple m menting a value based

care approach in reimbursement for

anybody unfamiliar value based care is

basically a person centered care team

approach that takes responsibility for

improving quality of care care

coordination and health outcomes in

order to reduce care fragmentation and

avoid unnecessary cost to the individual

and the Health Care

system now the trajectory of value based

care in the US is a datadriven approach

has two phases first we have the pay for

reporting ing phase where payers and

providers prove that they can report on

Dat certain data sets now up until now

with the onc CES act and CMS 9115f both

OWC and CMS have been in a pay for

reporting phase this phase is followed

by pay for performance where

reimbursement directly depends on

quality clinical data we're currently at

that juncture where onc standardizes the

data CMS then requires action on that

data and now the information blocking

penalties finalized via the Civil

monetary penalties information blocking

Rule and the oig which is the office of

the Inspector General has the ability to

enact civil monetary penalties we are

now in the pay for performance phase

from a planning and ecosystem

perspective everybody is about to get

graded and reimbursed based on their

data quality payers who use this

opportunity to enhance and streamline

their data sets to keep a golden record

with reconciled upto-date unduplicated

patient information will build value on

their clinically optimized data higher

quality data leads to higher

reimbursement so you should consider a

solution to these mandates not in a silo

but as part of a broader more strategic

data modernization

strategy additionally all Medicare and

Medicaid payers and providers will

inevitably move towards this new

interoperable system this means that

there's going to be a massive amount of

data flowing across these apis payers

who Implement and integrate workflows in

with a scalable solution will receive

the most Roi from this shift so you may

be wondering what does this ecosystem

view have to do with your business

operations today and future Revenue

stabilization well it means that payers

and providers have collected data and

pay for performing style pay for

reporting style and will now be graded

against pay for performance metric

this means that payer data needs to be

standardized and

inoperable as opposed to living in

clinical and vendor data silos where it

cannot be fully leveraged this makes

data actionable which can then be used

to create enhanced Revenue stabilization

from these value based care programs CMS

requires payers and providers to

communicate bidirectionally through

these data exchanges this is the only

way to above True interoperability is

Through Fire based integration now that

we're clear on what the rule entails and

It is peace in a larger ecosystem let's

look at four things that payers need to

consider today first do not

procrastinate from the proposed rule to

the finalized rule on the surface it

looks like CMS has extended some

deadlines upon deeper review it's clear

that this was done to allow

organizations time to implement these

complex Solutions properly so start now

because it will take time to evaluate a

solution implement one test it and then

deploy it at scale this year 2024 is the

year that payers should be assessing

their business technology and ecosystem

needs ideally have a vendor or solution

chosen by the end of 2024 payers who

have a strategy and a solution in mind

will be significantly ahead of the

market than those who do not payers who

delay in crafting their strategy will

likely face delayed Roi organizational

change management challenges and

resource crunches in the industry as

everybody faces to meet these deadlines

at the same

time second payers have to start

displaying data publicly by January 2026

publicly so if no improvements are made

for prior authorization adjudication in

2025 those public metrics will reflect

poorly when compared with payers who've

implemented an automated interoperable

fire solution and then this translates

down to Providers dis engine from payer

networks when they see those poor

metrics because of the administrative

burdens that translate down into

provider workflows and patient care

third electronic prior authorization has

inherent patient satisfaction

improvements as well as operational cost

savings by reducing payer and provider

staff burden sometimes up to 70 to 70%

in some scenarios as well as improving

the turnaround time and the visit

navigation for patients in general

implementing electronic prior off and

maintaining the necessary 5 years of

clinical and claims data per the CMS 57f

payer to payer API requirement on your

members, it will save you money in

operational costs and meta risk

assessment not to mention better patient

care and a better provider

experience lastly a requirement of this

prior Au rule is time frame for

adjudication the federal CMS requirement

is 72 hours for urgent requests and 7

days for non-urgent requests in the new

57f rule CMS also mentions that if state

requirements are more strict than

Federal runs State ones must be adhered to

for example Washington DC only allows

for 24 hours for Urgent prior author

requests as opposed to

72 Pennsylvania only allows for two days

for non for non-urgent requests as

opposed to seven uh seven days in uh

North Carolina only allows for one hour

for adjudication in emergency

stabilization scenarios as a clinical

informaticist a firsthand experience

with managing prior authorizations and

with complex Health Plan requirements um

additional information often needs to be

sent and requested and a lot of

communication issues I could tell you

that meeting that 1hour adjudication

time frame is nearly impossible under

Legacy systems without adding a vast

amount of administrative staff so

there's urgency in this process starting

it now and starting it off on the right

foot 2024 is the time to engage

a trusted vendor with intelligent Market

ready solutions that can respond to

requirements within the outline timing

provide real-time adjudication at scale

without compromising security and

improve utilization management as I've

mentioned path is a very

complex requiring strategy discovery

implementation and training so it's

going to require a partnership with a

team who understands IT smiles

solutions do all the above and more were

uniquely experienced in 2021 smile was

chosen as the number-one Vendor by

payers to support their implementation

of the CMS interoperability and patient

access final rule that was CMS

9115f we are already working with 20 of

the largest pairs in the us and our

offerings Touch One in three Americans

these pairs who have already engaged

with smile are well positioned to gain

Roi in 2025 based on all the

improvements and automations so let's

recap and outline the next steps prepars

as part of their strategy for this new

57f ruling one do not wait start

conversations within your organization

to plan and select solutions to

implement before the end of 2024 if you

wait you'll be looking at delayed Roi

from organizational change management

challenges low patient satisfaction

resource crunches in the industry as

everybody races to meet these deadlines

number two understand the business and

technical complexity of Prior

authorizations the implications

including state requirements to APIs and

Reporting requirements that are due in

2026 2027 and Beyond as well as your

Business Processes and Technology

strategy three get a head start over

your competition by improving your

processes in 2025 so that your 2026

reports show significant improvements to

11:04

your competitor's Legacy processes four

seek out a trusted vendor like smile

digital health is able to respond to all

these time frame requirements provide

real-time adjudication that's at scale

without compromising security and

improve utilization management so in

conclusion payers now in the spring and

summer of 2024 now is the time to access

business technology and ecosystem needs

and choose a vendor that will stabilize

and enhance Roi from CMS regulatory

requirements and value based care

initiatives if you haven't started your

process smile digital Health a smile

digital Health can help you by

completing an evaluation of your

existing systems to identify gaps

including security scale data exchange

workflow GL gaps and then make

recommendations and the best approach to

fill them and if you're wondering how

you can make these decisions as

part of a broader data modernization

strategy smile can show you our approach

to better data quality risk adjustment

and care coordination why wait contact

us today our detail our details are in

the video description below thank you

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