Open Standards Bring Healthcare Out of the Stone Age

Author:  Nikki Henck

July 15, 2022

Prior Authorization Series: Part 3 of 6

Breaking Down CMS Rule: How DaVinci Implementation Standards Fuel Interoperability and Enable Faster Decisions

Key blog points:

“Mired in the Stone Age.” That’s how former CMS Administrator Seema Verma characterized the current state of data sharing in the health sector. Her frustrations are mirrored throughout the industry, not least of all by payers and providers involved with prior authorization. 

The specific cause of this widespread aggravation is the difficulty in satisfying prior authorization requirements. Currently, healthcare providers work with various health insurers and payers who cover the services providers deliver to patients. Problems arise because different payers and plans provide varying levels of coverage for healthcare services—and each has different processes for determining whether services are necessary and appropriate.

These processes are often quite different between payers and require various documentation, largely facilitated through antiquated data exchange methods. To make matters worse, healthcare providers who fail to adhere to specific and exacting payer or coverage expectations may find that costs for a given service are not, or only partially, covered by the payer. This results in increased out-of-pocket costs for patients, additional visits, changes to the prescribed therapy and increased costs for providers. 

Determined to end the inefficient processes holding back healthcare, Verma expressed her frustration:

“When this administration took over, we understood that in a world where we can communicate instantaneously with someone on the other side of the globe, access our bank account from anywhere, that it wasn’t acceptable that our health information capabilities remain mired in the Stone Age,” Verma said in her speech to the ONC API event. “In 2020, faxes should not be the primary means of records transfer. We are used to a digital experience in every other facet of our lives, and it is high time healthcare caught up.” 

Fortunately, since the ONC API event there have been developments which indicate that an open standards approach is afoot. One development is the publication of the DaVinci Burden Reduction Implementation Guides (IGs), a set of three standards that establish electronic protocol for the coverage rules and documentation needed for electronic prior authorization. The DaVinci IGs establishes standards for:

  1. Coverage Rules Discovery
  2. Document Rules and Templates
  3. Prior Authorization Support

To understand the DaVinci IGs, it’s necessary to explore some of the technical details at the root of their changes. Starting with APIs.

What Is an API and What Does It Have to Do with Interoperability?

If there’s one key pain point that all payers experience, it’s a lack of patients’ medical data, which means a limited ability to make accurate and timely decisions. Patient care is further obstructed by inefficient and cumbersome prior authorization processes. That’s where APIs come in. 

Application programming interfaces, or APIs, enable interoperability between providers and their payer partners by facilitating the sharing, updating and consolidation of patient data – from medical history to treatment records, prescriptions and more. With APIs, doctors and payers have all the same information they need about a patient, can draw on that information on demand and are therefore able to make faster, more accurate decisions. 

But the benefits of APIs don’t stop there. They also help patients gain access to their own information as and when they need it. From a consultation with their general practitioner about their ongoing medical condition, to seeing an emergency room doctor for an unexpected health event, patients can rest assured that their information is available to those who need it, when they need it. Furthermore, patients can access their results, treatment options, diagnoses, and other information, without needing to see a doctor in person. This allows for self-directed consumer access to health data, resulting in higher health literacy and greater ownership of one’s health outcomes.

Additionally, APIs allow for “interfacing” between systems to exchange data, providing the functionality to update information in new technologies and systems that otherwise are too antiquated to change. By drawing on existing data sources and platforms, APIs also allow developers to build on top of existing applications, helping them build applications quickly and effectively.

How Does the DaVinci Project Play a Role?

“The FHIR-based APIs that we have used to expand patient access have significant untapped potential to unleash data and get it directly into the hands of all providers,” says Verma. “We need to ensure that patient data from other sources gets incorporated into the health record seamlessly, so that the data can be utilized. Electronic Health Records must finally become truly open and gain the ability to both read and write data in service of better care for patients, so that providers and payers alike – can make use of the data.”

The DaVinci Project is a collaboration of healthcare stakeholders with representation from provider, payer, regulatory and health-tech organizations seeking to facilitate interoperability.

The DaVinci IG for electronic prior authorization (ePA) is a suite of three standards for the implementation of ePA which will increase the efficiency of the process by ensuring that authorizations are sent when (and only when) necessary. The IG will also help to ensure that such requests will be more likely to contain all the information needed to make the authorization decision on initial submission. The IG intends to create standards to ensure consistency in the application ePA across digital platforms.

Breaking Down the Three DaVinci APIs:  CRD, DTR and PAS

Healthcare providers work with a range of different health insurers and payers who cover the services providers deliver to patients. Different payers and plans provide varying levels of coverage for healthcare services and each has different processes for determining whether services are necessary or appropriate. These processes are often quite different between payers and require different documentation, prior authorization or other approvals. Currently, healthcare providers who fail to adhere to specific and exacting payer or coverage expectations may find that costs for a given service are not, or only partially, covered by the payer. This results in increased out-of-pocket costs for patients, additional visits, changes to prescribed therapy and increased costs for providers. 

When combined together, the DaVinci IGs orchestrate a digital workflow that facilitates electronic pre-certification and enables real-time response from the payer. The workflow is enabled by:

  1. The Coverage Rules Discovery (CRD) API facilitates the discovery process by enabling payers to provide information about coverage requirements to healthcare providers, through their clinical systems at the time treatment decisions are being made. This will allow clinicians and administrative staff to make more informed decisions and more effectively meet the requirements of their patients’ insurance coverage–saving time, money, resulting in faster and more appropriate care.  
  2. The Document Templates and Rules (DTR) API enables payer rules to be executed in a provider context to ensure that documentation requirements are met. This results in a reduced burden on providers thanks to the reduced need for manual data entry. DTR leverages Clinical Quality Language (CQL), allowing payers to inspect a patient’s record for the necessary information related to the required documentation for a proposed item, certain medications, procedures or other services. 
  3. Prior Authorization Support (PAS) enables the direct submission of Prior Authorization requests from EHR systems using a standard already widely supported by most EHRs: FHIR. To meet regulatory obligations, these interfaces will communicate with an intermediary who, when necessary, will convert the FHIR requests to the corresponding X12 instances before passing on the requests to the payer. The responses are handled by a reverse mechanism (from payer to intermediary as X12, before being converted to FHIR and passed to the EHR). The ability to directly submit prior authorization requests from the EHR will reduce costs for both providers and payers and will result in faster prior authorization decisions which will lead to improved patient care and experience.

The collective implementation of these three components will result in the payer being able to obtain all the necessary information for a decision to be made promptly. With all of the information required and adjudication rules in place, payers can return a decision within seconds instead of hours or days.

How Payers Can Improve PAs for Their Provider Partners

Surveys show that most payers want to improve prior authorization for their provider partners. And it’s little wonder considering it’s not only good business practice to make providers happy, but it also results in a win-win scenario of reduced administrative burden for payers, more effective use of benefits and overall reduced ongoing healthcare costs for patients thanks to more timely and appropriate care (not to mention preventative care). 

With electronic Prior Authorization, practices can reduce their processing times by more than 85%—eliminating the need for multiple phone calls and faxes and the sheer frustration caused by not knowing where the request is within the PA journey. By reducing the administrative burden on providers, payers can make their provider partners more satisfied.

Accelerating Healthcare Transformation

As a world leader in interoperability, Smile Digital Health drives transformation in digital healthcare by standardizing how data is ingested and applied across the spectrum of healthcare. Smile seeks to enable payers to achieve a 60% or more reduction in the administrative burden from the prior authorization requirement through FHIR-based tools and services to support CRD, DTR and PAS. This will, in turn, result in enabling ePAs that will maximize efficiency for the payers’ provider partners, decrease costs associated with PA and increase satisfaction amongst providers.

While PAs are an important component of benefit designs, clinician offices can often be overwhelmed and confused by the submission process. Unlike the burdensome process that PA represents today, ePAs can be completed in minutes rather than hours (or in worst-case scenarios, days) and instead see a decision reached within seconds. This means that patients can schedule their services quickly, reducing gaps in care and improving their outcomes. Importantly for payers, they can easily implement more complex PA requirements, when necessary, without increasing the provider’s administrative workload. ePA ensures appropriate utilization of healthcare services while reducing administrative hassles for prescribers. 

Smile and the DaVinci Project are facilitating this revolution, bringing about a new age of healthcare with interoperability at its core.

To continue learning about the Prior Authorization Series, read our blogs:

Part 1: Why the CMS Prior Authorization Rule Is a Win for Providers and Payers
Part 2: A Mutual Burden for Providers and Payers and How Interoperability Can Facilitate Change
Part 3: Breaking Down CMS Rule: Open Standards Bring Healthcare Out of the Stone Age
Part 4: How CDS Hooks Will Break Down Data Silos in Healthcare
Part 5: Harnessing the Real Power of Data Interoperability
Part 6: Coming Soon…