A Call for Innovative Partnerships with CMS

The Centers for Medicare & Medicaid Services (CMS) has taken a monumental step towards transforming healthcare practices with its recent move to streamline the prior authorization process. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) signifies a pivotal moment in healthcare, projected to bring about significant cost savings of $15 billion over the next decade. This bold initiative is poised to alleviate administrative burdens, empower clinicians, and eliminate avoidable delays in patient treatment, ultimately improving the overall health outcomes of millions.?

The New Requirements

The CMS ruling introduces comprehensive requirements for impacted payers, focusing primarily on Medicare Advantage organizations, Medicaid-managed state and care plans, and qualified health plan insurers on the federally facilitated exchanges (FFEs). Commencing in 2027, these entities are mandated to comply with the following key provisions:

1. Expedited Decision Timelines:?For urgent prior authorization requests, payers must send decisions within 72 hours, while standard (non-urgent) requests require decisions within seven calendar days. This swift decision-making timeline aims to enhance patient care by minimizing unnecessary delays.
2. Specific Denial Reasons:?Payers are now obligated to include a specific reason when denying a prior authorization request. This transparency ensures that healthcare providers have clear insights into the decision-making process, fostering collaboration and understanding between payers and providers.
3. Public Reporting of Metrics:?Like Medicare Fee-for-Service (FFS), impacted payers must publicly report their prior authorization metrics annually. This increased transparency is expected to enhance accountability and facilitate a more-informed healthcare landscape.
4. Implementation of FHIR??Prior Authorization API: To streamline electronic prior authorization processes, payers must implement a Health Level 7 (HL7?) Fast Healthcare Interoperability Resources (FHIR?) prior authorization application programming interface (API). This technology-driven approach aims to automate the end-to-end prior authorization process, promoting efficiency and reducing manual workload.

Learn more: CMS Finalizes Revolutionary Prior Authorization Rule?

API Requirements & Compliance Timeline

The ruling places significant emphasis on the adoption of Health Level 7 (HL7?) Fast Healthcare Interoperability Resources (FHIR?) prior authorization API. The compliance timeline, initially set for January 1, 2026, has been extended to January 1, 2027. This extension allows impacted payers to expand their current patient access API, ensuring the inclusion of vital prior authorization information. There’s real potential for a partnership between CMS and technology-enabled services companies to improve healthcare access and equity .

Browse the Ultimate Guide to Prior Authorizations.

NaviNet's Role in the Transformation

As the healthcare industry moves towards full compliance, platforms like NaviNet stand as key enablers of this transformative impact on prior authorizations. NaviNet aligns with CMS requirements, leveraging technology to reinforce the vision of a streamlined, cost-effective, and patient-centric healthcare system. By supporting stakeholders in improving patient care and enhancing data interoperability, NaviNet contributes to the positive shift in the healthcare landscape.

Download the Prior Authorization Playbook to simplify your organization’s prior authorization process without requiring dramatic changes to provider behavior and payer workflow processes.

Partnerships and Innovations

While CMS has historically partnered with traditional healthcare entities, there is a unique opportunity for collaborations with technology-enabled services companies. Innovations from startups and digital technology firms can address key barriers and advance CMS's mission of improving healthcare access and equity. Four pivotal opportunity areas include improving consumer awareness, mitigating access gaps through virtual care programs, streamlining payer plan models, and addressing social risk factors without imposing additional burdens on providers.

Challenges and Recommendations

Consumer awareness, especially regarding CMS programs, remains a challenge. Digital platforms can play a crucial role in centralizing education and outreach initiatives to improve awareness. Additionally, virtual care solutions can mitigate access barriers, especially for underserved populations. Standardizing credentialing and billing operations among plans and implementing cross-state licensure will alleviate provider burdens and enhance healthcare access.?

Addressing Social Determinants of Health

Identifying and addressing social risk factors is integral to achieving health equity. CMS can invest in methods to streamline the process, reducing provider burden. Leveraging technology-enabled remote workforces, such as community health workers, can effectively address complex patient needs, improving clinical outcomes and reducing healthcare costs.

The CMS ruling and the subsequent initiatives present a monumental opportunity for the healthcare industry. By embracing technology, fostering innovative partnerships, and addressing key challenges, CMS can lead the way towards a more accessible, equitable, and efficient healthcare system. The estimated $15 billion in savings over the next decade underscores the financial benefits, emphasizing the positive trajectory towards a streamlined and patient-centric future.

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