By: Sanjeev Jayakumar, Principal – Product Engineering, LTIMindtree

On January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule (CMS-0057-F). It is a comprehensive initiative aimed at reshaping data exchange in the healthcare ecosystem. As the healthcare industry shifts toward more efficient, patient-centric processes, the mandates outlined in CMS-0057-F present an important opportunity for improvement in health information exchange, ultimately providing appropriate and necessary access to patients’ health records. It will enable seamless data exchange and minimize the heavy administrative burden of prior authorization processes.

The role of APIs and FHIRs in enhancing interoperability

At the heart of this transformation, application programming interfaces (APIs) and fast healthcare interoperability resources (FHIR) standards play a key role in improving healthcare interoperability. APIs facilitate the connection of systems like electronic health records (EHRs), payer platforms, and mobile apps to ensure efficient, secure data sharing between patients, providers, and payers. By supporting FHIR standards, APIs enable consistent and reliable electronic sharing of patient data, breaking down silos and fostering better communication across platforms. This ensures interoperability and sets the stage for improved care delivery.

Furthermore, the CMS-0057-F rule builds on the CMS Interoperability and Patient Access Final Rule from 2020, incorporating feedback and extending to Medicare Advantage plans. Together, these standards align policies with the growing need for a connected healthcare environment.

Here are the top five takeaways for interoperability and how to successfully navigate the evolving healthcare landscape:

1. An opportunity for efficiency and improved outcomes
   CMS-0057-F is often viewed simply as a regulatory requirement, but it should be seen as a chance to drive transformative change in healthcare. The mandate for FHIR-based APIs is poised to streamline prior authorizations, improve decision-making, and enhance overall health outcomes. Embracing these changes can lead to a more efficient and streamlined ecosystem for payers, providers, and patients alike, with the ultimate goal of improved care.

2. Time is of the essence
   Most major provisions of CMS-0057-F, including the implementation of all new APIs have a deadline of January 2027.  This leaves Payers with just 21 months. Moreover, the first set of Patient Access API usage metrics should be reported by March 31, 2026, and this should cover Prior Authorization usage data for the 2025 calendar year.  Thus, payers who have not yet started collecting Patient Access API usage metrics are at a serious disadvantage. Overall, failure to act now could put organizations behind schedule, making it harder to meet the deadlines and putting their compliance at risk.

3. Non-compliance consequences
   Non-adherence to CMS-0057-F API implementation deadlines could be construed as “Information Blocking” as defined in the 20th Century Cures Act, and lead to severe penalties – including up to $1 million per incident. Additionally, payers could face revocation of their Medicare/Medicaid licenses and suffer negative impacts on their STAR ratings. These consequences highlight the importance of taking immediate action to align with the new regulations in a timely manner and avoid costly setbacks.

4. The importance of APIs and FHIR interoperability
   APIs improve healthcare data exchange by connecting systems like EHRs, payer platforms, and mobile apps, enabling seamless sharing of information between patients, providers, and payers. The new APIs mandated under CMS-0057-F include:
   • Provider access API: Allows providers to directly access claim, encounter, clinical, and prior authorization data for their patients from payers, through requests initiated from their EMR systems.
   • Payer-to-payer API: Enables payers to access historical claim, encounter, and clinical data for a member from a previous or concurrent payer.
   • Prior authorization API: Provides providers with the ability to query payers for detailed information via their EMR systems.

   By supporting FHIR standards, APIs allow consistent electronic sharing of patient data, ensuring interoperability across different systems for more efficient care.

5. Why partner with an expert?
   Navigating CMS-0057-F compliance can be complex, but partnering with experts can make all the difference. Such companies have established strategic partnerships to tackle compliance needs effectively. Leaning on experts and leveraging their innovative technology to expedite implementing CMS-0057-F will be a key factor in accelerating adaptation to this new standard.

Conclusion:

Embracing CMS-0057-F offers an exciting opportunity to transform the healthcare ecosystem, improving efficiency, reducing costs, and enhancing patient outcomes. However, navigating the complexities of the mandate requires expertise, collaboration, and strategic planning. By partnering with trusted industry leaders, payers can ensure that they meet regulatory requirements and set themselves up for long-term success.