What payers and providers need to do to comply with upcoming government mandates

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A number of federal policies have gone into effect since the beginning of 2021, while other policies will be implemented over the next several years. Payers and providers alike need to understand what these various government mandates include so they can work closely with their compliance teams to ensure they’re ready to meet the requirements.

During a featured session as part of the 2021 Becker's Healthcare Payer Issues Virtual Summit (which was sponsored by Change Healthcare), Ed Hafner, AVP of payer strategy at Change Healthcare, shared key information that payers and providers need to know regarding current and future U.S. government mandates and rules.

Four key takeaways were:

1. The CMS Interoperability and Prior Authorization rule would enhance patient access to information. This rule, which is currently under review, builds on the existing CMS Interoperability and Patient Access final rule, requiring that government payers provide information to patient members, including pending and active prior-authorization decisions.

Members of federal and state Medicaid, Children's Health Insurance Program, CHIP fee-for-service programs, and qualified health plans on federally facilitated exchanges will enhance their member-facing APIs, adopting specific schemas via application-programming interfaces so that members can more easily use the app of their choice to access data. In addition, health plans would be mandated to adopt FHIR APIs to support the prior-authorization process with providers. "Patients can browse provider directories, look at their pharmacy information, and [access] information that will help them better manage their care and have an improved prior-authorization process," Mr. Hafner said.

2. CMS final rules put consumers at the center, providing them control over their healthcare data. Over the next several years, commercial payers will be required to offer increased transparency to members. The recently adjusted July 2022 mandate requires payers to post two machine-readable files every month — in-network and out-of-network— with plain language, billing-code descriptions, negotiated rates, and other information to help patients better understand the cost of care.

The second phase of the rule focuses on self-service: An online self-service tool with pricing for 500 shoppable services is planned for January 2023, and online pricing and cost sharing for all items and services is coming in January 2024.

3. The No Surprises Act improves patient protection against unexpected costs. The first part of this act's interim final rule focuses on commercial payers, putting in place regulations that limit surprise expenses being passed on to the patient. "There used to be a surprise when the patient would go to the network facility and would find that one of the providers was out of network," Mr. Hafner noted. This new rule includes limiting the surprise cost of an out-of-network provider at an in-network facility. It also includes protections for emergency-services coverages for out-of-network providers, emergency air ambulance bills, and balanced billing (also called surprise billing), as well as an avenue for provider-health-plan disputes. Additional aspects of this bill are expected to go into effect in 2022, while others may come later.

4. A provision specified within the No Surprises Act is the advanced explanation of benefits provided to members, along with a good-faith estimate. Patients will be able to request an explanation of benefits that offers estimates of expected charges, the plan's payment responsibility and member out-of-pocket expenses, deductibles, and out-of-pocket maximums. If services are out of network, the EOB must include a description of how to obtain in-network provider information. Guidance is anticipated after Jan. 1, 2022.

Because all these policy changes could affect payers and providers in a material way, it is important to thoroughly understand these mandates and be prepared to comply with them.

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