New CMS Payer Rules Bring Unproven Solutions to Market
In December 2022, the Centers for Medicare and Medicaid Services (CMS) proposed a new rule to streamline the prior authorization process in healthcare. This rule mandates that certain payers make health information readily available at the point of care by leveraging the use of the HL7® Fast Healthcare Interoperability Resources (FHIR®) standard.
It’s a change that will move the entire industry toward electronic prior authorization. And the fact that payers will soon be looking for a new wave of FHIR solutions hasn’t gone unnoticed by big tech companies.
With these CMS rules on the horizon, the entire industry is eager to capitalize on an opportunity for new business. As a result, we’ve seen several announcements of new FHIR-based solutions from some of the biggest names in tech. Despite this, many of these organizations have not been able to keep up with the interoperability promises made in their initial announcement, leading them to step away from FHIR as quickly as they approached it. This is because organizations that haven’t taken the time to learn the intricacies of FHIR have struggled to leverage its multi-purpose functionality to create the robust product offering needed to facilitate interoperability.
That’s why, it’s important that Payers maximize the benefits of adopting FHIR by selecting the right FHIR vendor. Payers who are interested in securing the best FHIR product offering should look no further than Smile’s health data fabric (HDF). Smile’s HDF leverages the functionality of FHIR to provide the holistic support needed to manage the new clinical workflow demanded by the CMS proposed rule.
But to develop a strategy for compliance, you’ll first need to look at the new CMS requirements and discover how you can set your organization up for success with FHIR.
New CMS Rules Advance Interoperability
Titled “Advancing Interoperability and Improving Prior Authorization Processes,” the proposed CMS rule is designed to help reduce the burden on payers, patients, and providers during the prior authorization process by improving health information exchange.
To accomplish this, CMS is mandating:
Automated Processes: Payers will be required to implement an automated prior authorization process using a standardized interface called the Fast Healthcare Interoperability Resources® Prior Authorization Requirements, Documentation, and Decision API (FHIR PARDD API). This automation aims to streamline the prior authorization process by proactively sharing a payer’s prior authorization requirements and communicating prior authorization decisions.
Shorter Timeframes: Decision-making timeframes for prior authorization requests will be reduced, ensuring faster access to care. For example, certain impacted payers would be required to send standard prior authorization decisions within 7 days and expedited prior authorization decisions within 72 hours.
Public Reporting: Payers will be required to publicly report specific prior authorization metrics annually, providing insights into how prior authorization is used. These metrics include approval, denial, and appeal rates, as well as average decision times.
Provider Information: Using a FHIR API, payers will be required to share information about prior authorization status with healthcare providers, including whether a request was approved, denied, or requires more information. This change enhances transparency and care coordination.
Data Exchange: Payer-to-payer data exchange will be facilitated through a FHIR API, where payers can share claims, encounters, and prior authorization data. This change reduces the burden on patients when switching health plans, and provides patients with an opt-in option for data sharing.
Understanding the Options: FHIR APIs vs. Health Data Fabric
For payer organizations that haven’t adopted FHIR as an organizational standard, complying with these new CMS rules may seem like a heavy lift. This has prompted big names in the industry to start “playing with FHIR” by adding interoperability support over existing applications and data services.
It’s a strategy that entices payer organizations to “add on” FHIR Application Programming Interfaces (APIs) to an existing service, while relying on name recognition that’s been established in other areas. But while FHIR APIs will help payers comply with the new CMS rules, they’re just one small step toward realizing the complete benefits of having an organizational strategy supported by FHIR. That’s why, to get the most out of data exchange, you’ll want a health data fabric.
Standalone FHIR APIs, like the new options coming onto the payer market, use a set of rules and protocols that allow different software applications to communicate with each other using the FHIR standard. They allow payers to share health data with authorized stakeholders, and enable the exchange of information across disparate systems.
But the Smile Digital Health HDF does all that and more, by offering a modern, holistic framework for managing and accessing data across an organization's diverse data landscape.
As an enterprise-level FHIR data interoperability and exchange platform, Smile HDF takes interoperability to the next level. Instead of exporting data from one system to another, the HDF uses open standards to create a unified layer of data that’s available to any application, empowering organizations to disseminate information across networks, at scale.
It delivers the capability for applications to drop in and out and participate in a consistent information model of other platforms. The benefits include a hybrid storage solution, active intent, standardized schema and coding, realized semantic interoperability, native knowledge graphs, and a healthcare industry data value domain.
The Value of Choosing an Experienced FHIR Partner
When choosing a solution for FHIR implementation, experience matters, too. With FHIR API solutions for payers, interoperability is being viewed as a means to an end. As a result, there can be a lack of deep expertise and experience when it comes to true health data interoperability.
Now, compare that approach to Smile. Our company’s experience with FHIR dates back to the origin of the technology itself. Smile’s Chief Technology Officer, James Agnew, is one of the original contributors and main players of HAPI FHIR. He’s been championing open-source-based healthcare interoperability for decades, and is widely regarded as one of the top industry thought leaders.
For Smile, FHIR is more than just a product offering. It lies at the very core of who we are as a company. Since Smile’s first commercial release in 2016, our team of experts has been building innovative, enterprise-ready solutions that are tailored to the needs of payers, providers, researchers, and government entities.
Compared to other FHIR APIs, Smile HDF offers a more robust enterprise level FHIR solution. Our high-performance, secure, and scalable platform can provide the platform expertise, features, and support you need for a successful FHIR implementation. Smile HDF is cloud agnostic, meaning it can be deployed anywhere. And our managed services offer end-to-end implementation management for a hassle-free go-live experience.
When taken as a whole, Smile delivers a level of FHIR expertise, service, and support you won’t get anywhere else. So what are you waiting for? Contact us today to learn how Smile can help support the next step of your FHIR journey and stay compliant with new CMS mandates.