Payer-to-payer data exchange rule will be released ‘soon’, CMS lead tells #HIMSS22


Diving brief:

  • The Biden administration has been working on developing additional rules to address issues with the payer-to-payer data exchange requirements set out in the sweeping interoperability rules finalized in early 2020, and “we look forward to sharing this rule with you soon”, CMS administrator Chiquita Brooks-LaSure told the participants of the HIMSS annual conference in Orlando on Tuesday.
  • CMS decided not to apply these provisions when they come into effect this year, after health insurers raised concerns about operational challenges and risks to data quality given the lack of specificity of the ruler.
  • The new rule will incorporate extensive public comment to try to address stakeholder concerns and standardize how payers exchange data through application programming interfaces, Brooks-LaSure said.

Overview of the dive:

The CMS rule was released in tandem with a sister rule from the Office of the National Coordinator for Health Informatics in March 2020, intended to push the healthcare industry towards free and unfettered electronic sharing of data among patients. , payers and providers. However, some rule requirements have been delayed to free up resources during COVID-19, while others, such as payor-to-payer exchange provisions, have yet to come into effect or be enforced.

The CMS rule requires plans participating in federal programs to provide patients with free electronic access to their personal health data, including medical claims and encounter information, including costs. It also requires plans to make their provider directories available to current and potential enrollees via API technology, in the hope that insurers will transfer these practices to private plans as well.

Originally, plans had to share certain clinical information with each other at the patient’s request, allowing patients’ cumulative health records to follow them as they transitioned between insurers and plans.

However, payers criticized this segment of the rule, saying it would be very difficult to implement and could lead to a patchwork system of reporting, as there was no requirement for a standardized API for sharing data.

In December, CMS formally exercised its enforcement discretion regarding this provision, meaning it would take no action against a health insurer if it did not exchange data with other payers at the request of a patient within the initial period.

The agency pledged to require payer-to-payer data exchange, but “the policy that CMS finalized didn’t quite achieve its goal,” Brooks-LaSure said Tuesday. “Our interoperability rule was not interoperable enough and left too many open questions about how data is exchanged.”

As such, the agency has been working to take the next rule “above and beyond” by weaving in plenty of public commentary and making sure it includes the requirements for a data-based API. standards, said Brooks-LaSure, such as an API-compliant FHIR Health Level Seven, which the government has chosen as the national standard in its interoperability work.

Agencies like CMS and ONC that are active in health informatics continue to seek other ways to build on interoperability regulations, mandated by the 21st Century Cures Act passed in 2016. Currently, CMS is working to define the interoperability of healthcare directories and exploring what role the agency should play in managing them, while considering how technology can be used to streamline the prior authorization – a major source of controversy for payers and providers.

CMS is also working with ONC on updating the USCDI dataset which is the backbone of data types that must be interoperable to comply with the rules, Brooks-LaSure said.

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