CMS published the CMS Interoperability and Patient Access Final Rule in the Federal Register on March 4, 2019, the pre-publication text of the final rule was released on March 9, 2020, and the final rule was published in the Federal Register on May 1, 2020. The rules are effective as of January 2021 and will be enforced by July 2021.

The overarching goal is to make patient data more useful and transferable through open, secure, standardized, and reduce burdens on healthcare providers.

“We believe patients should have the ability to move from health plan to health plan, provider to provider, and have both their clinical and administrative information travel with them throughout their journey.”¹  The rule is one of several CMS initiatives intended to “empower patients and encourage plan and provider competition.”

Overall, the rule aims to achieve four main goals:

The responsibility for implementing changes to comply with the Final Rule impacts three main groups, health plans, hospitals, and state Medicaid agencies. If you boil it down to its simplest form:

• Must implement Patient Access Application Programming Interfaces (APIs) for claims, encounter, clinical & formulary/PDL for dates of service after 1/1/16
• Must implement Provider Directory API
• Must implement payer-to-payer data exchange

• Must implement Admission, Discharge & Transfer (ADT) notifications
• Should ensure they attest to not information blocking
• Should ensure their digital contact information is up to date with CMS

• Must implement Patient Access APIs for Medicaid & CHIP FFS
• Must implement payer-to-payer data exchange
• Must submit Medicare Modernization Act (MMA) (State-Phasedown File) for Part A & B buy-in daily

The CMS per plan cost estimate is $788k – $2.5M, depending on organization type with a minimum six-month implementation. These estimates are a general range and could vary for your organization as there are several factors to consider beyond market type, such as resource availability (the potential need for IT contractors) and any type of provider contracting impact or policy updates. An important note for payers is that depending on the market (individual, small group and large group) costs associated with data exchange may qualify as “quality improvement activities” for purposes of your insurer’s medical loss ratio (MLR).

Stay tuned next week for Part 2 of our Interoperability Rule Blog Series titled “Making the Economics Work for You,” focused on how this may impact you from a cost perspective and how you can capitalize on your investment and optimize your ROI.

Interested in talking to our team to help guide you through the process? Click here.

¹ Interoperability and Patient Access – Prepublication Final Rule – (CMS-9115-F) p. 8. https://www.cms.gov/files/document/cms-9115-f.pdf