Interoperability, APIs and CMS' final rule: 5 key insights for payers to meet compliance


HHS' interoperability rules aim to make it easier for consumers to access their own health information, which will require payers and providers to adopt new technologies and data-sharing standards to adapt to the new digital world.

The rules, issued by CMS and ONC, will make it easier for patients to access and share their health data. Focusing primarily on provider regulations, ONC's rule targets interoperability and information blocking practices, while CMS' rule requires payers to give their members access to administrative, clinical, and directory/formulary data via application programming interfaces.

The CMS rule focuses on requirements for organizations that provide products for CMS sponsored programs including Medicare, Medicaid and the ACA plans on the federal exchange. During a July 9 webinar hosted by Becker's Hospital Review and sponsored by Change Healthcare, industry experts discussed key compliance dates and regulations for the CMS Interoperability and Patient Access final rule (CMS-9915-F) and how the health IT company's solution can help payers prepare.

The speakers were:

  • Ed Hafner, Associate Vice President of Payer Strategy at Change Healthcare
  • German Scipioni, Vice President of Connected Consumer Health services at Change Healthcare
  • Bob Hoover, Vice President of Consulting at Change Healthcare

Five takeaways from the webinar:

1. Major provisions of the CMS rule. Under the rule, health plans must provide APIs that allow plan members to use third-party apps to access their health information, as well as access to a standard API that gives members access to the plan's provider pharmacy directory data and formularies. While the compliance deadline for the rule is set for Jan. 1, 2021, enforcement has been delayed due to the COVID-19 pandemic.

2. Think beyond the rule. Change Healthcare advises health plans to think of the CMS rule as more than just a compliance project, but rather as a chance to increase member engagement. "These capabilities will provide health plans a new platform to achieve member engagement and move to meet the expectations of consumers and how they want to interact with the healthcare system," Mr. Hoover said. "Think about how you personally interact with other industries. Healthcare needs to be able to get to that point, and that's really what this digital transformation is about." Change Healthcare’s Connected Consumer HealthTM platform allows access to additional functions that support the entire member journey, including capabilities such as Member Payments.

3. Assess interoperability readiness. The Connected Consumer Health interoperability solutions help healthcare organizations meet CMS rule requirements. The platform manages and checks which information the payer needs to provide on its website and then merges members' financial and clinical data so third-party apps can technologically connect to available APIs, according to Mr. Scipioni.

4. Deliver fast healthcare interoperability APIs from a clinical perspective. Using the repurposed Connected Consumer Health platform, the Change Healthcare interoperability solution translates and stores member data, such as roster files, EOB information, encounters, and clinical data, on behalf of the health plan. The company then normalizes the data into a health cloud within its Amazon Web Services environment and is "able to then provide all the other services - including data translation and patient matching - that are required to vet identity, authentication and consent management," and deliver the FHIR APIs to the third-party app,” Mr. Hafner said.

5. Free APIs or hosted solution. Change Healthcare offers free APIs for organizations that already have a Health Level 7 FHIR-based API. Acting as a third party, Change Healthcare gives payers the opportunity to connect to its hosted API solution, which handles consent management and other responsibilities designated by CMS.  A hosted API solution also is available for organizations just starting out on their interoperability journeys. It helps health plans collect the necessary member data, reducing the resource needs required to quickly deploy the full set of required interoperability capabilities.  

"We will process that data, attach identity and convert it to HL7 [the body that sets FHIR standards]," Mr. Scipioni said. "We will make it available in real time so that when an API call comes in, we can actually answer it in a 1-2 second response time for that API."

Click here to view the full webinar.

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