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CMS Interoperability Rule requires payers to grant data access to their members

On March 9, 2020, the Department of Health and Human Services issued two new rules regarding the interoperability and patient access provisions of the 21st Century Cures Act impacting CMS-regulated payers.

Key actions required by Jan. 1, 2021:

  • Implement and maintain an API that allows members/patients to easily access their claims, encounter, and clinical data using the HL7 FHIR Release 4.0.1 standard.
  • Enable public access to provider directory information via the API.
  • Exchange specific clinical data with other payers as requested by the patient/member.

Impact to payers

The interoperability rule gives payer organizations until January 2021 to implement a public-facing API that allows patients/members access to their claims, encounter, and clinical data. To meet this deadline, payers need to mobilize now to define and execute on a strategy for health data sharing based on the new Fast Healthcare Interoperability Resources (FHIR) standard adopted by CMS. 

The current rule requires CMS-regulated payers implement an API based on the ONC (Office of the National Coordinator for Health Information Technology) rule also published on March 9 that defines the data sharing standard. ONC adopted the HL7 FHIR Release 4.0.1 as their standard for the required API.

Payer’s API must support patient information requests for claim, encounter, and clinical information; provide the capability to share data requested by the patient/member with other payers; and enable public access to their provider directory information.

Potential Penalties: The Cures Act that authorizes the CMS rule also provides for potential penalties of up to $1 million dollars for organizations found to commit information blocking (not sharing required data); however, the actual rules for the penalty have not yet been written. 

How Baker Tilly can help

Your public data sharing infrastructure will be an increasingly important foundational capability as these guidelines grow and more complex contracts come to fruition. Baker Tilly’s experienced healthcare and digital transformation consultants can work with your organization to enhance your systems:

  • Analyze current data sharing infrastructure. Determine the capability and barriers of your current data sharing architecture to publicly share data effectively.
  • Recommend digital data sharing strategy. Define the organization’s data sharing strategy. Develop a digital transformation roadmap that supports immediate deadlines and builds a foundation for future capability.
  • Implement digital transformation. Rapidly stand-up a project team to implement the transformation, including the technology and process implementations.
  • Manage the change. Build and execute a change management plan to ensure adoption of any workflow changes and to communicate relevant data sharing strategy messaging to key stakeholders.

Connect with us to discuss how your organization can best approach compliance with the new interoperability rule provisions.

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