The new CMS Rule for admission, discharge and transfer (ADT) notification for Conditions of Participation (CoPs) requirements and shared risk arrangements officially went into effect on May 1, 2021. This rule was enacted to improve coordination of care between hospitals and the post-acute provider teams, both streamlining and enhancing communication. It is these provider teams that play such a critical role in providing patient care post-discharge.
As part of the larger Interoperability and Patient Access Rule, the last mandate looks to ensure effective health data exchange between providers that will ultimately lead to better patient outcomes and a lower cost of care. However, provider to provider communication is not the only focus of this latest CMS regulation.
Lack of Timely Admission, Discharge, Transfer Information:
An ADT event notification can give payers tremendous foresight to prepare to engage and support their members more proactively. With real-time notifications, payers have the ability to digest and understand their members with full clarity. Without these alerts, payers are unable to successfully manage the care and other issues, like readmissions, and increased costs for both the payer and the member.
"Payers are at a significant disadvantage by not understanding the treatments their members are getting or, almost more importantly, what treatments they aren't getting. And that gap in care is so important to meet not only just better health outcomes but also a very long and complicated list of CMS HEDIS quality metrics put in place to encourage health plans to think about its members that are not getting some care that they should be getting." – Bevey Miner Consensus Health IT Strategy/CMO
Proactive Care Coordination
ADT event notifications provide necessary information about patients that allows payers to track and implement health plans promptly, especially for high-utilization members or high-risk members. If adequate information is not communicated while patients are transitioning from one care facility to the next, health plans come to a halt because they are unable to engage the necessary resources prior to patient discharge.
This point was driven home in the article by my colleague Edie Hagens, Senior Business Development Executive, Healthcare at Consensus, saying, "Well implemented technology at the point-of-care enables collaborative decision making for providers and health plans to effectively triage care for the best possible outcomes."
Payer Enablement of Interoperable Real-Time Notification Solutions
Payers have tremendous power to assist providers in advancing healthcare interoperability through the adoption of real-time notification solutions. This exchange of health information between payers and providers will be instrumental to their performance in risk-based care models.
"I anticipate that there will be help from the payer community to support more collaborative data sharing within provider EMR workflows versus sending docs out to portals… Far beyond simply finding a patient or member, we need to focus on an interoperability framework that supports clinicians efficiently in their existing EMR workflow and beyond with meaningful data." – Edie Hagens, Senior Business Development Executive, Healthcare at Consensus
Electronic Prior Authorization (ePA)
When evaluating the traditional approach used to submit prior authorization requests, it is clear most of the responsibility falls on providers. Each health plan is unique in that it has its own payer-specific portal containing different clinical and business rules. Add in distinct CMS rules, and you have one elongated process comprised of many documents that need to be processed by a payer.
In many instances, the request for prior authorization is going to sit there. That's not good, considering some PAs can be life-critical, such as a chemo patient who needs to have prior authorization before she can move on to another set of chemo treatments. It can also be very difficult for the patient.
Efficient and effective health data exchange is essential to the right care being delivered at the right time for the right treatment. With the adoption of an all-in-one real-time health event notification solution like Consensus Signal, payers can work alongside providers to ensure that their members are on a path to better health outcomes that reduces waste and frustration.
About Bevey Miner:
Bevey Miner serves as Health IT Strategy/Chief Marketing Officer, Consensus Cloud Solutions – the creators of the Consensus healthcare data-sharing platform and eFax Corporate, the leader in HIPAA-compliant healthcare fax technology.