The CMS will not take any enforcement action for the payer-to-payer data exchange in the May interoperability rule.

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The Centers for Medicare and Medicaid Services announced that it will not take enforcement action against certain payers for the payor-to-payter data exchange provision of the Final Rule of Patient Interoperability and Access from May 2020 through. ‘that the future regulations are finalized.

The agency’s decision to exercise its enforcement discretion for the pay-to-pay policy does not affect any other existing regulatory requirements and the implementation timelines described in the Final Rule.

On July 1, two of the policies in the May 2020 Interoperability and Patient Access Final Rule came into effect. On April 30, requirements for hospitals with certain EHR capabilities to send admission, discharge, and transfer notifications to other providers came into effect, while on July 1 CMS began enforcing requirements for certain payers to support patient access and provider directory APIs.

The regulations include policies that require or encourage payers to implement application programming interfaces (APIs) to improve the electronic exchange of health data – sharing information with patients or exchanging information between a payer and a supplier or between two payers. APIs can connect to mobile apps or a vendor EHR or practice management system to enable a more transparent method of exchanging information, according to CMS.

The regulations also include policies that aim to reduce the burdens of the pre-authorization process by increasing automation and encouraging improved policies and procedures, with the goal of streamlining decision-making and communications.


The final rule on interoperability and patient access was to give patients access to their health information when and how they wanted. The rule was intended to promote interoperability and patient access to health information by freeing up patient data using the authority of CMS to regulate issuers of Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program ( CHIP) and Qualified Health Plan (QHP) on Exchanges (FFE).

CMS exercised discretion to enforce the Patient Access API and Supplier Directory API policies for MA, Medicaid, CHIP, and QHP issuers on ETFs from January 1 to July 1. CMS began implementing these new requirements on July 1.

The rule of interoperability and prior authorization proposed prior rule. It emphasizes the need to improve the exchange of health information to achieve appropriate and necessary access to complete health records for patients, health care providers and payers.

This proposed rule also focuses on efforts to improve pre-authorization processes through policies and technologies. It improves some policies of the CMS Patient Interoperability and Access Final Rule and adds several new provisions to increase data sharing and reduce the overall burden on the payer, provider and patient through proposed improvements to practices. ‘preliminary authorisation.


CMS first introduced the Final Rule for Interoperability and Patient Access in December 2020. It received mixed reactions from providers as the American Hospital Association applauded efforts to remove barriers to patient care by streamlining the prior authorization process, but was disappointed that Medicare Advantage plans were left out.

U.S. health insurance plans spoke out against the rule in a statement by Chairman and CEO Matt Eyles in January.

The statement lambasted CMS for rushing finalization of the rule and said it was “constructed in a shabby and hasty fashion”. He likened the rule to “putting an airplane in the air before the wings are bolted” because insurers are required to build these technologies without the necessary instructions.

While AHIP has insisted that the country’s health insurers are committed to creating a better connected health system, it says the rule cannot be implemented as is, puts patient data in danger and prevents stakeholders from defeating COVID-19.

Twitter: @JELagasse
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