Tag: Joe Gagnon

Interoperability and Prior Authorization Are on FHIR

Joe Gagnon

Responses from Joe Gagnon, CEO, 1upHealth.

The recently released CMS Interoperability and Prior Authorization final rule is a pivotal measure to reshape the industry. By laying the groundwork for expanded access to health information and streamlined prior authorization processes by mandating the use of FHIR APIs, this regulation takes a critical step toward using comprehensive, timely data to support value-based care initiatives, reduce costs, and improve outcomes.

As stakeholders navigate the ever-changing interoperability landscape, the first step is tapping FHIR APIs to ensure compliance and adaptation to shifting tides. From there, organizations can look beyond compliance to see how FHIR APIs can open the door to next-level innovation and usher in a future where efficiency, collaboration, and patient-centric care take center stage. 

  1. What are three ways the new CMS interoperability and prior auth rules will impact healthcare organizations?

Overall, the new rules serve as a critical foundation for expanding access to health information and improving the prior auth process in healthcare.

For all stakeholders, the collective FHIR APIs provide the ability to use comprehensive, timely claims and clinical data to support value-based care programs by implementing a common data approach to leverage historical patient data to maximize quality outcomes for patients. These initiatives are critical to reducing healthcare delivery costs while maximizing patient quality in real time. Additionally, as acutely acknowledged by CMS in its rule commentary, while many patients over the course of a year can have a significant number of providers, it is likely that they will only have one or two payers, thus making the making payer the prime hub in a hub-and-spoke style data sharing model.

For payers, if the FHIR APIs are implemented and utilized as advised by CMS, the respective APIs will not only have the ability to materially improve the ability to share relevant data in a more timely manner, it will also significantly reduce the cost and administrative burden of such data sharing. Today, many payers have entire departments that are focused on packaging and sending data to relevant provider partners. By automating the data sharing process with FHIR APIs, not just for CMS compliance but for all other interoperability use cases, payers can ‘kill two birds with one stone’ and meet regulatory requirements while also creating internal efficiency and significantly improving access to data, as outlined above.

For providers, using interoperable data for prior authorization can help make patient care decisions more quickly, improving patient, provider, and payer alignment and ultimately improving outcomes.

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