Interoperability

Medicare payments could soon be on the line for hospitals and doctor’s offices found blocking the free electronic flow of health information.

That’s if a new rule proposed by the HHS on Monday is finalized.

Under the rule, providers that block the access, exchange or use of electronic health information could lose out on select annual payment increases, receive lower quality scores or be kicked out of a value-based program in Medicare.

“I think these are going to be very powerful incentives to change the whole national conversation,” said Don Rucker, who led the Office of the National Coordinator during the Trump administration. The ONC oversees U.S. health IT.

“The way they resonate through the payment system — this directly affects the payment systems of providers,” Rucker said.

Long-awaited penalties

Providers have been waiting for regulators to add teeth to rules forbidding information blocking that were finalized in early 2020. Specific punishment for health IT vendors found information blocking was included in the law backing the rules — an up to $1 million fine per violation, which regulators officially enacted this summer.

The statute — the 21st Century Cures Act passed in 2016 — did not include specific penalties for providers. Instead, Congress left it up to the secretary of the HHS to establish disincentives, without granting the department any additional authority. That lack of clarity complicated oversight efforts, according to senior government officials.

Monday’s proposal “starts the process to fill in the last remaining oversight aspects” of the information blocking rules, Steve Posnack, deputy national coordinator for health information technology, told reporters during a Monday press conference.

Experts have slammed the lack of data-sharing enforcement on healthcare providers as a major oversight, since providers account for the majority of information blocking complaints, according to government data.

The new rule attaches providers’ Medicare payments to information blocking compliance. The move was appropriate given the intent of the statute, according to Rucker.

“It’s highly in line with public policy and the pretty clear intent of Congress in the Cures Act,” Rucker said.

Under the proposed rule, hospitals participating in the Medicare Promoting Interoperability Program (MPIP) — which pays providers for EHR adoption and use — won’t qualify as meaningful EHR users if they’re found guilty of information blocking.

As a result, hospitals could lose 75% of the annual market basket increase. Critical access hospitals would have their payments associated with successful participation lowered to 100% of reasonable costs, instead of 101%, according to the HHS.

Similarly, in the Merit-based Incentive Payment System, or MIPS — Medicare’s reimbursement program for physicians that includes bonus payments for EHR use — clinicians that block data sharing would not be certified as meaningful users of EHR technology.

As a result, they would receive a zero score in the interoperability performance category. That category typically accounts for one-quarter of a medical group’s total MIPS score in a year, according to the HHS.

In addition, providers in accountable care arrangements in the Medicare Shared Savings Program (MSSP) would become ineligible for the program for at least a year if found information blocking.

‘A little less’ severe

The proposed rule is not economically significant, meaning regulators don’t expect the financial effect of those penalties to stack to more than $200 million a year. Still, providers could lose out on significant Medicare dollars under the proposal.

In MPIP, the size of a penalty would depend on the guilty hospital’s Medicare payments, but the average penalty would be $394,353, according to an ONC blog post Monday.

For MIPS, the median disincentive amount is an estimated loss of $686 per clinician. Providers removed from MSSP would lose any revenue from that program as well.

Those financial penalties could be powerful, especially for smaller medical practices where every dollar matters, said Kyle Meadors, a principal consultant at health IT consultancy Chart Lux.

But “I was kind of surprised that it was frankly a little less expensive and probably less harsh than [penalties for] corresponding EHR developers,” Meadors said. “The bar seems to be higher for developers across the board.”

The ONC also plans to publish the names of actors found guilty of information blocking, along with any penalties they received. Stakeholders have previously called for more transparency in the data-sharing oversight process, though the ONC has declined to share names of entities accused of, but not found guilty of, information blocking.

That “wall of shame” could be a successful disincentive for providers looking to avoid embarrassment, Meadors said.

The HHS is likely to face provider backlash against the proposals, given they impose additional costs, according to Rucker.

But “it’s hard to complain about being dinged for information blocking when you’re getting paid under a program called Promoting Interoperability,” Rucker said.

Looking forward

The ONC said Monday’s proposed disincentives, which would kick in upon finalization of the rule, are a first step toward provider enforcement.

That’s because the CMS programs that would include the disincentives don’t include all types of providers — for example, entities like renal dialysis facilities, emergency medical services providers, pharmacists and labs wouldn’t be affected, though they do fall under the regulatory definition of a healthcare provider.

The ONC is working to identify applicable programs and authorities where it could enact disincentives for those groups, according to Posnack. Currently, regulators don’t have a set timeline for proposing additional penalties.

But “we’ll continue filling in pieces of the puzzle,” Posnack said.

Regulators face other thorny questions as they look to finalize the disincentives, including how the new rule squares with other regulations that affect information blocking, such as the HIPAA privacy rule.

Investigating information blocking complaints will also be tricky, since in many cases it may be unclear whether providers or their health IT systems are to blame, experts said. There may also be cases where a provider acts as a health information exchange, so could be exposed to multiple types of penalties.

“It is going to be hard to draw the line,” Meadors said.

Dive Brief:

• The Biden administration has renewed its contract with the Sequoia Project, allowing the nonprofit to continue overseeing the country’s nascent network for nationwide healthcare interoperability over the next five years.
• With the new contract, the Sequoia Project will stay on as recognized coordinating entity, or RCE, for the Trusted Exchange Framework and Common Agreement, a key patient health data-sharing initiative that’s slated to go live later this year.
• The Sequoia Project has received almost $3 million in government funding since it began serving as RCE in 2019. The nonprofit will receive $2 million in the first year of its new five-year contract — the only year that’s been funded so far, according to a spokesperson.

Dive Insight:

The Office of the National Coordinator, which oversees U.S. health IT, selected the Sequoia Project as the first RCE in 2019.

As RCE, the Sequoia Project is responsible for developing and implementing the Common Agreement portion of the TEFCA interoperability guidelines — creating baseline technical and legal requirements for different health IT systems to communicate with each another and share electronic information.

The Sequoia Project also helped the ONC choose qualified health information networks, or QHINs, and is responsible for monitoring the groups along with modifying and updating their technical requirements.

The renewal of the Sequoia Project’s contract comes at a key time for TEFCA.

The initiative — a provision of the 21st Century Cures Act passed in 2016 — was finalized in early 2022. After receiving applications for candidate QHINs, the HHS approved the first six QHINs for onboarding in February this year.

That list of organizations that intend to complete testing and onboarding by the end of 2023 has since grown to seven, and includes major EHR vendor Epic and a number of interoperability infrastructure organizations.

The Sequoia Project is a public-private partnership that advocates for nationwide health IT exchange. The group was founded in 2012 and has been in charge of the nationwide health information network exchange, called the eHealth Exchange. It became an independent body in 2018.

The Biden administration has released a sweeping new rule touching on multiple aspects of health information technology in the U.S., including proposals meant to create more transparency and trust in clinical decision support software.

The rule proposed Tuesday would give providers more information in their electronic health record system to assess clinical decision support algorithms and their results.

The changes would promote greater trust in predictive decision support interventions, and help providers assess their applicability for a particular patient population or circumstance, the Office of the National Coordinator for Health IT said.

Artificial intelligence has a potential to cut costs and improve care delivery in healthcare, including in the area of clinical decision support. AIs are trained on datasets to find patterns and make recommendations to clinicians, like alerts for adverse medication interactions or potential cases of sepsis.

Demand for clinical decision support is rising as physicians try to keep up with rapidly shifting medical knowledge and recommendations. In addition, mounting data suggests tools can help fend off adverse outcomes for patients.

However, regulating algorithms has historically been a gray area, until Food and Drug Administration guidance last year broadened the agency’s oversight of clinical decision support software, including those that provide a specific diagnostic or treatment suggestion.

Now, the ONC — which regulates health IT systems that can include the AI tools — is proposing new regulations meant to make more information about the algorithms available in the EHR for providers, ONC head Micky Tripathi said on a Tuesday call with reporters.

The rule proposes a new certification criteria for clinical decision support algorithms, to keep pace with advances in decision-making software.

Along with defining algorithm-based, predictive decision support interventions, the rule requires certified EHRs that enable or interface with the software to allow users to review information about additional source attributes, including around health equity. The rule also requires developers of certified health IT modules to undergo intervention risk management practices for all the predictive decision support interventions they interface with.

Together, the proposals should improve transparency and promote trustworthiness of clinical decision support tools by enabling users, like providers, to better scrutinize them, the ONC said.

New info blocking condition for TEFCA

The rule is also proposing to add new information blocking flexibilities for organizations that participate in the Trusted Exchange Framework and Common Agreement, the government’s nascent framework for nationwide health information exchange.

Since participation is TEFCA is voluntary, there have been questions around industry buy-in since it was finalized over a year ago. Some stakeholders have argued that regulators should exempt organizations that participate in TEFCA from information blocking stipulations, to incentivize companies to join by reducing their compliance burden.

Now, the ONC is proposing a new information blocking condition for parties that participate in TEFCA.

If a TEFCA participant offers to fulfill a data-sharing request from another TEFCA participant through the framework, they wouldn’t be required to offer that data in any alternative manner — even when the data might exceed the minimum data classes and elements required in the Common Agreement.

The proposed manner exception says it’s reasonable for an information blocking actor to prioritize using TEFCA means to send data over other feasible ways.

This approach furthers both the goals of TEFCA adoption and interoperability, according to the final rule.

Other changes

The proposed rule would discontinue year-themed editions of ONC certification criteria for health IT. Instead, it would establish a single set of criteria that would be updated incrementally, with the goal of aligning with standard development cycles and making it easier for health IT developers to maintain their product certificates over time.

The rule also includes provisions meant to help individuals and providers, including those engaged in public health, to securely access electronic health information through broader adoption of standardized application programming interfaces.

It would also standardize electronic case reporting, with the goal of facilitating faster disease tracking and case management, after the lack of a nationwide reporting infrastructure hamstrung the public health response during COVID-19.

Regulators are also proposing that developers adopt the third iteration of the U.S. Core Data for Interoperability dataset by 2025. The dataset would be expanded to include additional data elements related to public health, sexual orientation and social determinants of health.

The proposed rule would also clarify the infeasibility exception to the information blocking rules.

The ONC has yet to finalize a long-awaited regulation creating appropriate disincentives for providers found information blocking. That regulation now has a tentative release date of September.

Regulators also expect to release new standards for EHRs, including expanded uses of APIs around electronic prior authorization and patient engagement, in November.

Dive Brief:

• On Monday, the HHS unveiled the first six networks that have been approved to be onboarded as qualified health information networks, or QHINs, under TEFCA, the government’s framework for a nationwide health information exchange.
• It’s been about a year since the Office of the National Coordinator for Health IT released TEFCA, or the Trusted Exchange Framework and Common Agreement. Now, Epic, CommonWell Health Alliance, eHealth Exchange, Health Gorilla, Kno2 and Konza — organizations that collectively cover a significant swath of American health records — have committed to become eligible and go live within TEFCA in 12 months.
• A number of additional organizations are readying themselves to apply into the voluntary framework, said Mariann Yeager, CEO of the Sequoia Project, ONC’s private-sector coordinating partner for TEFCA, at a Monday HHS event. “This is just the beginning,” Yeager said.

Dive Insight:

Interoperability is critical for national healthcare infrastructure, HHS officials said Monday, and improving it will bring down costs while also improving care delivery.

Bringing the new prospective QHINs on board is a great start to improving the U.S. healthcare systems’ interoperability, but there’s a lot more work to do to address the digital divide between well-resourced and struggling providers, a lack of connectivity with public health agencies, sparse information sharing between payers and providers and little patient access to their own information, ONC head Micky Tripathi said.

“Our vision is that TEFCA can get us out of the collective shared helplessness that we’re in,” Tripathi said.

The 21st Century Cures Act passed in 2016 required the government to create a set of foundational principles for health information exchange, under a contract establishing a technical infrastructure model and governing approach.

TEFCA’s goal is to create a simplified and standardized connectivity infrastructure for providers, plans, patients and public health agencies. The effort builds on the progress of national networks, state and regional health information exchanges that facilitate secure exchanges of millions of medical documents each day.

The Biden administration early last year finalized TEFCA and opened a window for organizations to apply to be designated as QHINs, or groups of organizations that agree to the same data sharing infrastructure. That connects them to one another and enables their participants, including providers, payers and public health agencies, to exchange health information across the country.

The six potential QHINs unveiled Monday have 12 months to be onboarded, but that work could be done by the end of 2023, Tripathi said. Some of the QHINs, including electronic health record giant Epic, had already announced their intention to join.

The number of QHINs isn’t set in stone. An HHS spokesperson told Healthcare Dive they “continue to receive interest from a diverse range of organizations,” including health information networks and EHR vendors.

But the six organizations alone cover a significant number of Americans. Though it’s difficult to pin down an exact number given the overlap in covered lives, collectively the QHIN applicants have networks that cover most U.S. hospitals and tens of thousands of providers, and process billions of transactions annually across all fifty states, the ONC said.

Moving forward, the ONC plans to announce additional QHINs when they're designated.

Dive Brief:

• The Biden administration on Tuesday finalized penalties for health IT companies found blocking the electronic flow of health information, freeing regulators to start investigating the backlog of information blocking complaints.
• The HHS Office of Inspector General final rule enacts statutory penalties created by the 21st Century Cures Act, including fines of up to $1 million per information blocking violation.
• Regulators have yet to codify information blocking penalties for providers, a separate rule that’s been held up amid enforcement complexity and is now expected to be published this fall.

Dive Insight:

The Office of the National Coordinator in 2020 finalized long-awaited regulations requiring providers, health information exchanges and health IT developers certified by ONC to share data with patients and with each other. The rules resulted in more hospitals electronically sharing health information, though data exchange is still patchy across the U.S., which complicates quality of patient care between care sites.

Regulators also in 2020 proposed new civil monetary penalties for health IT vendors and networks to enforce that rule, which are now final.

Having a stick in place to enforce compliance three years after the original rule is expected to more firmly move the needle on interoperability in U.S. healthcare.

“The industry has been awaiting this rule and we anticipate that it will be one more step in ensuring that electronic health information is flowing in support of patient care,” ONC head Micky Tripathi told Healthcare Dive in a statement.

Violators can face fines of up to $1 million, but regulators will determine the exact amount based on factors including the nature and extent of the information blocking, and the harm that resulted from it, such as how many patients were affected.

The OIG rule also outlines priorities in investigating and punishing information blocking claims. The department expects to get more complaints than it can investigate, Andrew Vanlandingham, OIG’s health IT policy lead, said in a tweet on Tuesday.

As a result, investigations will focus on cases of information blocking that had the potential to cause patient harm, impacted providers’ ability to care for patients, went on for a long time, caused federal healthcare programs to lose money or were performed knowingly.

The OIG also said it might prioritize investigations based on the volume of claims alleged against a single actor.

“Our enforcement priorities will inform our decisions about which information blocking allegations to pursue, but these priorities are not dispositive. Each allegation will present unique facts and circumstances that must be assessed individually,” the 130-page final rule reads.

“We can and do expect to investigate allegations of other information blocking conduct not covered by the priorities ... And as we gain more experience with investigating information blocking, we will reassess our priorities accordingly,” regulators noted.

Some comments on the proposed rule suggested the OIG should turn to less punitive measures than monetary penalties, like educating actors found guilty of information blocking or issuing corrective action plans. Regulators said “at this point” they don’t anticipate using alternatives to fines, though the OIG will have a self-disclosure protocol to allow for lower penalties.

The OIG said it could also refer allegations to other agencies, including the ONC and the HHS Office for Civil Rights, that have other authorities to issue corrective action plans or additional fines.

“As we gain more experience investigating and imposing [civil monetary penalties] for information blocking, we may further consider alternative enforcement approaches,” the rule reads.

Since April 2021, the ONC has received more than 700 possible claims of information blocking, but regulators have been unable to start investigating the allegations without a final rule around enforcement.

Now, the OIG could begin enforcement as soon as this summer. The final rule will go fully into effect 60 days after it is published in the Federal Register.

The wide majority of information blocking allegations have been levied against healthcare providers, which still don’t face any penalties for information blocking.

The timeline to finalize a regulation that would establish disincentives for providers has been pushed back multiple times. However, once the penalties are established, enforcement will fall under the just-released OIG rule, according to the ONC.

Regulators have run up against a slew of difficulties in crafting a rule that could stand up to industry scrutiny, Tripathi told Healthcare Dive late last year.

Interoperability continues to improve among U.S. hospitals, but there’s still a ways to go, according to new government data.

More than six in 10 hospitals electronically shared health information and integrated it into their electronic health records in 2021, up 51% since 2017, the Office of the National Coordinator released in a Thursday data brief.

The availability and usage of electronic data received from outside sources at the point of care has also increased over the last four years, reaching 62% and 71% respectively in 2021.

The brief illustrates the progress that’s been made in hospitals using electronic data to provide care, and sharing it with other providers outside of their networks, as facilties adopt government-certified EHRs and pivot to comply with interoperability regulations stemming from the 21st Century Cures Act. However, discrepancies among providers indicate ongoing challenges.

For example, rural and small hospitals saw rates of available electronic information at the point of care increase by more than 26%, to reach 48% in 2021. In addition, rural and small hospitals’ use of information received electronically from outside facilities grew twice as fast as all hospitals nationally over the four years studied.

But these smaller hospitals, which generally have fewer resources than their larger counterparts, aren’t on par with larger peers in terms of having full access to electronic information from external sources, the report said.

Other barriers to information exchange also remain sticky. For example, 48% of hospitals said they shared patient data with other providers who don’t share patient information with them.

The ONC also found that roughly four in 10 hospitals participate in multiple health information exchanges, or data-sharing networks. The agency said the findings reinforce the need to have multiple networks at play, and the importance of policies that facilitate cross-network exchange, such as the Trusted Exchange Framework and Common Agreement launched last year.

TEFCA’s goal is to create a framework for nationwide data exchange, though its voluntary nature has raised concerns about industry buy-in. However, a number of entities have applied or said they plan to apply to be certified as qualified health information networks in TEFCA, including EHR giant Epic and existing HIEs like Carequality and eHealth Exchange.

Regulators are still working to implement provisions of 21st Century Cures, including potential punishments for providers and vendors found information blocking. 

The government is authorized by statute to issue up to $1 million in civil monetary penalties against health IT vendors found guilty of information blocking. However, regulators have yet to finalize a rule proposed in 2020 outlining how their investigations will be performed and the size of penalties. In addition, the HHS has yet to define penalties for providers found blocking the free flow of information due to enforcement complexity, ONC head Micky Tripathi has told Healthcare Dive in December.

Back when America adopted the main law for medical privacy and technology, the most popular mobile device was a pager, home movies played on VHS at Blockbuster, and the leading search engines were AskJeeves, AltaVista and Dogpile. 

Our times and tech have changed, but the famed HIPAA law of 1996 — the Health Insurance Portability and Accountability Act — remains stuck in the bygone era when the Macarena was still king. 

Fortunately, there’s a bipartisan push in Washington to update the law, sponsored by Sens. Tammy Baldwin of Wisconsin and John Cassidy of Louisiana. That bill calls for a commission to review existing state and federal protections of personal health information, as well as current practices for health data use by the healthcare, insurance, financial services and consumer electronics industries. It also is to recommend to Congress whether federal legislation is needed to modernize health data privacy. 

As an RN and CEO of a healthcare company, I’m hoping we can update HIPAA in a way that not only acknowledges the value of new health apps and Fitbit-style monitoring devices, but also scales back the silos around health data so providers can respond to a wider, fuller picture of a person’s health.  

In the 1990s, legislators, consumers and medical professionals were justifiably concerned about the use and disclosure of personal health information. The result was the one part of the vast law that consumers are most familiar with — the HIPAA Privacy Rule. 

Intentions were good, as were many results, but the law hasn’t kept pace with the technological reality of today.  

One unintended consequence was the compartmentalization of medicine. HIPAA makes it tougher to share health data, a change obvious to any patient who has had the frustrating experience of having to fill out forms and repeat their medical history every time they see a new doctor, physician assistant, nurse or health insurance rep. 

Have you ever tried to assemble and review your own medical history? This is no easy task — it’s extremely walled off. If it’s so hard for you to get your own records in one place, then you can imagine how difficult it is for the professionals trying to gain a complete health picture so they can understand, treat and cure you. 

HIPAA has encouraged the rise of giant electronic health record companies like Epic and Cerner, which have set up cloud-based repositories of patient records — and then built moats around them. They figured out that if you control the data, you control the game. That might be good for their business, but it impedes the ability of providers to understand and improve a person’s health based on their life story.  

Fragmented medicine makes healthcare more difficult. At a time when we need to be considering the health of a whole person, our system is set up instead for different medical specialists to view people through their particular specialist eyes. A patient isn’t a living, breathing human with complex needs and varied dreams. She’s viewed on the medical conveyor belt as a broken hip, or a high blood pressure that needs to come down, or a cancer that needs to be radiated away.  

In my own business of complete senior health, our members have lived full lives, often after being treated by many different medical providers. Yet the burden is on the individual to tell their story, their life journey, with every provider at every point of service time and again. It’s incredibly frustrating that the healthcare business can’t aggregate the story and the information around the person, in our case, seniors.  

Though tech platforms like Facebook, iCloud and Google Photos have greatly advanced the ways that people can record, remember and share major life events, there is no similar and straightforward way to capture and understand their full medical story. (By the way, Facebook, Google and the cloud did not exist when HIPAA was approved.) Clearly the tech is possible to help medical record keeping if we put the proper safeguards around it. 

Is there any other business that makes the customers repeat, again and again, why they are here, how they arrived, when they last visited, what they hope to gain from this visit — and if they recall doing anything years ago that might have any relevance to what we want to do now? 

Omissions, faulty memories, unclear dates — there are just so many opportunities for errors in this process, both from patients and providers. Yet we keep repeating it. 

Having a single data source to tell the whole healthcare story would make it so much easier to improve care and tailor services to the individual.  

At the same time, personal medical privacy must be protected. The key here is that the health data must be made to work best for the consumer, whose wishes should get top priority over the companies trying to capture the data and commercialize it. 

Technology and data can do so much to help improve our health. With an update of HIPAA, we need to make sure that medical information is available to help and illuminate instead of being walled off in a frustrating turf battle

Google is continuing to explore a consumer-facing health record, more than a year after first launching a user feedback program, according to Chief Health Officer Karen DeSalvo.

“We’re still testing and learning,” DeSalvo told Healthcare Dive at the HLTH conference in Las Vegas on Tuesday. “It’s an ongoing curiosity.”

The tech giant is testing and evaluating features of a personal health record, not currently building a standalone tool, as it weighs big questions like how it should be hosted and whether consumers even want a personal health record, DeSalvo said.

Tech giants including Google have tried and failed to create a consumer-friendly electronic health record, though efforts have been revitalized amid recent government regulations freeing up medical data from siloed systems.

Google first launched a user feedback program last April to see how patients might want to keep and view their medical data after pulling it from provider patient portals, STAT News reported.

The user testing comes more than a decade after Google attempted to create a new digital health record in 2008, called Google Health. Google shut down the high-profile project after four years, citing difficulties getting adoption into the daily health routines of patients.

Yet consumers have become increasingly open to accessing their health information electronically. The number of hospitals allowing patients to use third-party apps to view data jumped from 2018 to 2019, and more U.S. patients are using online portals to access medical information, according to government data.

Google’s efforts around patient medical records comes as rival company Apple launched a health records section in its Health app in 2018. The app allows users to pull their records from hospitals and medical offices and hold that data on their iPhone.

Despite disbanding its health-specific unit last year, Google has remained active in the healthcare industry, creating new provider appointment scheduling capabilities online and launching tools to help healthcare companies make their medical images more interoperable and actionable through AI and machine learning.

Google Health is focused both on coordinating health ventures internally and linking different offerings. That ethos has given rise to products like Device Connect for Fitbit, an integration between Google Cloud and Google’s wearables business that launched in September, and a new app, called Health Connect.

Device Connect for Fitbit is meant to make it easier for healthcare and life sciences organizations to use Fitbit data for patient monitoring, research and population health projects, according to the company.

Health Connect, which rolled out on Monday, assimilates data from eligible health, wellness and fitness apps and brings it onto a single platform. The app allows Android users to sync and track their lifestyle goals in one place using data from variety of participating apps, like Peloton, Oura and Flo.

Also on Monday, Google Cloud announced it was linking with EHR giant Epic to build an offering that will allow clients to run their Epic workloads on Google Cloud, and launched three new healthcare data engine accelerators to address common pain points for health system clients.

Dive Brief:

• Major hospital and payer associations put aside their numerous policy differences last week to co-write a letter to the CMS asking the agency to clarify conflicting rules they say would enact different data exchange standards for prior authorization reviews.
• The American Hospital Association, American Medical Association, AHIP and Blue Cross Blue Shield Association sent a letter to the CMS on Thursday arguing that two December proposed rules, if finalized, would “set the stage for multiple [prior authorization] electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate.”
• The Administrative Simplification rule would enact standards around when payers and providers send healthcare attachments to support claims and prior authorization transactions. Meanwhile, the Interoperability and Prior Authorization rule includes different requirements for when government-sponsored insurers such as Medicare Advantage plans share information when processing prior authorization requests.

Dive Insight:

The CMS has been trying to streamline prior authorization, a process in which physicians request approval from an insurer for medication or treatment before administering it. Payers and providers have long been at odds over prior authorization. Providers cite it as a roadblock to timely patient care and a source of documentation burden, while health insurers say the requirements are necessary to curb unnecessary medical spending.

However, groups representing both sectors now agree on one thing — the government implementing mismatched provisions in rules that intend to standardize data exchange processes is bad for all parties involved.

“We are concerned by the conflicting provisions of [the rules] that would establish two different sets of standards and corresponding workflows to complete [prior authorizations], depending on the type of health plan,” the coalition wrote in its letter to CMS Administrator Chiquita Brooks-LaSure.

The Interoperability and Prior Authorization rule requires federally regulated health plans to offer application programming interfaces to support electronic prior authorizations relying on one data exchange standard, called HL7 FHIR. However, the Administrative Simplifications rule requires a combination of HL7 and another standard called X12, and would apply to all health plans, according to the letter.

“For federally regulated plans, this would require cross walking the two standards for no discernable benefit,” the groups argue.

The conflicting CMS provisions would cause “widespread confusion,” “slow implementation” and be “enormously expensive for both health plans and providers,” the letter says.

Some payers have been walking back prior authorization requirements, including UnitedHealthcare, which said in March it planned to eliminate almost 20% of its prior authorizations starting this summer. The payer also in June rolled back a plan to require prior authorization for colonoscopies and other endoscopic procedures, though it did enact an advance notification process opposed by providers.

Last year, CVS-owned Aetna rolled back prior authorization requirements on cataract surgeries, video EEGs and home infusion for some drugs.

More than a third of physicians say prior authorization requirements are to blame for a serious adverse event for one of their patients, including hospitalization, permanent impairment or death, according to a March AMA survey.

Almost half of the physicians surveyed said prior authorization leads patients to seek urgent or emergency care.