In the blog series covering the 21st Century Cures Act, we have discussed the key focus areas so far and presented an analysis of the new certification criteria. In this blog, we will venture into the world of payers – and discuss how the CMS Final Rule on Interoperability and Patient Access will impact payers.

Enhancing patient engagement is the cornerstone on which healthcare regulations are built. Much like the regulations stipulated by the 21st Century Cures Act, the Interoperability & Patient Access Rule will enable the patient to have better access to their health information as well as give them greater control, break the silos that exist within the healthcare ecosystem and make it easier for payers to deliver services efficiently.

Here’s a summary of how the new policies under this rule will impact payers:

Patient-access API: Payers are required to maintain a secure, standards-based API that will allow patients easy access to their claims and other clinical information through any third-party apps of their choice. Combining clinical data and claims data will offer a holistic understanding of the patient’s interactions with the system, leading to better health outcomes.

Provider directory API: Payers must make the provider directory information publicly available via a standards-based API. This policy will drive innovation by allowing third-party app developers to access information that benefits both patients and providers. For instance, app developers may use this information to create services that help patients find the right providers for their health condition. For clinicians, this information may prove useful for knowledge-sharing and better care coordination.

Payer-to-payer data exchange: Payers are required to exchange specific patient clinical data at the patient’s request, allowing them to take their information with them as they move from payer to payer. This policy will help create a comprehensive health record with their current payer. It will also ensure all of the patient’s information resides in one place and speed up decision-making, leading to faster and more effective care delivery.

Improving the dually eligible experience: For patients who are covered by both Medicare and Medicaid, this policy will improve the dually eligible experience by increasing the frequency of federal-to-state data exchanges from weekly or monthly to daily. It will ensure that beneficiaries can access services as and when they require and are billed the first time accurately, thus reducing wastage.

The patient holds the key

The Interoperability and Patient Access Rule underscores the importance of giving more power to the patient. Now is the right time for payers to do a gap analysis to assess their current technical capabilities versus the measures to ensure compliance. The new policies will help payers have greater visibility and allow easy transition of information to patients and their care providers. Payers must assume a guide’s role in helping patients who may struggle with handling multiple apps and data in the coming years. With the rule adding more players in the ecosystem, the future of healthcare seems to be more open, accessible, and flexible, with the patient holding the key to their care.


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