The Interoperability Rule and Effects on Provider Network Data

clinician wearing lab coat with files

The Interoperability Rule, currently slated to go into effect in 2021, makes significant patient health data requirements, but how will the rule impact provider network data for health plans?  In this post, we discuss the rule’s direct implications for provider network data and how innovative payers are leading the way in the broader trend toward interoperability. 

The Rule’s Goals and Current Timeline

The Interoperability Rule delivers on a promise defined by CMS’s MyHealthEData initiative to put patients first, giving them access to their health information when they need it most and in a way they can best use it. This rule focuses on defining the requirements for certified Health IT Products utilized by providers. It has essential information blocking provisions targeted at providers, developers of certified health technology, payers, and other health information networks. This is accomplished by liberating patient data using CMS authority to regulate Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).

The rule itself has guidelines around adopting standardized application programming interfaces (APIs). This will allow easier access to health information for patients and providers alike through something as accessible as a smartphone application. The rule also states that patients can access their health information at no cost and implement the Cures Act’s information blocking provisions.

The timeline for this rule taking effect was initially intended for a starting date of January 1, 2021. As a result of COVID-19, and to provide additional flexibility to payers, requirements will not be enforced until July 1, 2021. This extension has allowed provider networks to focus on their strategy to prepare for the Interoperability Rule to take effect. 

The Provider Directory API

CMS-regulated payers (except QHP issuers on the FFEs) are now required to make provider directory information publicly available through a standards-based API. Defining these standards and making this information available will encourage innovation by allowing third-party application developers to access the information they need to create services that help patients find providers and help clinicians find other providers for care coordination. Making this information more widely accessible is also a driver for improving the quality, accuracy, and timeliness of this information in the most user-friendly and intuitive ways possible.

Provider directory requirements include:

  • Data Standard – FHIR® 4.0.1 (R4) API
  • Required Data – Provider names and network status, addresses, phone numbers, specialties
  • Timing – Provider directory updates must be available via API within 30 days of receipt of new data or directory data changes.
  • Security – Public-facing API endpoint

While the changes may bring about much-needed reform, challenges can be expected, especially in the payer’s case. Reaching the new standards will often require an investment in new foundational technology to support a scalable solution. Additional resources will be needed for training on the latest standards and systems, as well as an expected learning curve for everyone involved.

What the Interoperability Rule Means For Providers

The new rules are great for patients; however, they place a significant burden on payers, providers, and health IT vendors.  The responsibility falls on their certified Electronic Health Record systems (EHRs) to meet most of their compliance requirements for providers. This rule also reinforces the idea that people don’t need to choose between privacy and transparency regarding patient data. 

The call for open APIs with predictable standards will allow healthcare organizations of any size to improve care coordination and share information securely with their patients. It also removes ambiguity around data standards, so healthcare organizations will communicate more efficiently with partner organizations when patients are being transferred to different facilities.

What the Interoperability Rule Means For Payers

Payers will need to develop a strategy to hit these milestones over the next year. A strategy that will enable them to gather and share data on provider payer amounts, patient cost-sharing information, clinical data points, and more. This strategy will require critical IT investments to ensure compliance requirements are met while also balancing consent, privacy, and comprehension on behalf of their members. 

How Payers Are Preparing

These rules will significantly impact healthcare providers, health plans, health IT vendors, and patients in the years ahead. Healthcare providers and health IT companies should assess their practices involving electronic health information (EHI) to ensure that they are not intentionally or inadvertently engaging in “information blocking.”  

Section 4004 of the Cures Act defines information blocking as the intentional withholding of information either from provider to provider or provider to patient. Potential penalties for information blocking include fines of up to $1,000,000 per violation. Provider data is often hard to find and overlooked. This rule will allow patients to quickly find which doctors are in-network, their locations and contact information, and ensure they have the proper up-to-date licensing. 

Healthcare providers and payers should prepare for greater automated access to their patients and plan members’ health information. They should provide education for their patients and members about the benefits and potential risks of using third-party apps to access and aggregate their information.  Payer-to-payer data transfer technology is also included in the finalized rule. Still, it has not been defined with technical standards yet, as it is set to go into effect in January 2022.

How to Prepare for the Interoperability Rule to Take Effect

Throughout the healthcare industry, the first step toward compliance with the the Interoperability Rule is to identify tools, systems, and applications that hold data elements needed to support interoperability. Understanding the qualified data is essential when preparing for interoperability because every business process captures and maintains information differently.

The ONC rule will require data to be more standardized, imposing terminology standards on the information’s meaning. Once data is identified and mapped, it is essential to develop a compliance strategy and implementation plan. Healthcare organizations must assess what’s needed to update their technology, define a path forward, and certify the exchange of healthcare information.

As the timeline continues to move closer, determining a strategy may seem like the biggest challenge of it all. Forward-thinking solutions for providing smarter, safer healthcare can help healthcare organizations face the challenges of assessing, defining, and implementing the technology needed to support interoperability. If your organization is looking for ways to move through this process and provide safer healthcare monitoring successfully,  please get in touch.

Learn how provider eligibility monitoring can improve Provider Directory accuracy.

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