Welcome to the third of our business and healthcare law firm’s holiday-themed blog posts. This week’s post is inspired by my favorite holiday movie, A Christmas Story, and the eloquent words Ralphie wrote: “A Red Ryder BB gun with a compass in the stock, and this thing which tells time.” Analyzing Ralphie’s literary genius, he gave Miss Shields three enticing facts: the main description, a vital component, and an interesting addition. Following suit, I will provide three enticing facts of CMS’ new proposed rule.
First, the shortened name of the rule is: “Reducing Provider and Patient Burden by Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Information.” According to CMS, the purpose of the proposed rule is “[t]o drive interoperability, improve care coordination, reduce burden on providers and payers, and empower patients.” The ingenuity of the proposed rule stems from the fact that it is not only designed to grant patients better access to their records; it is designed to grant all vital parties’ necessary access to records—meaning patients, payors, and providers.
Second, the new rule requires each payer to use an Application Programming Interface (“API”) that allows each payer’s system to communicate with other payers. The new rule also does not require patients to request the transfer of claims data. As such, a patient’s new payer will have access to all of his or her claims data almost immediately upon enrollment. Importantly, on the new API, payers can send “patient claims, encounter data, and clinical data directly to providers.” Verma, Seema, Reducing Provider and Patient Burden and Promoting Patients’ Electronic Access to Health Information, CMS.gov (Dec. 10, 2020).
Third, the proposed rule attempts to improve the prior authorization process. Prior authorization is the administrative process by which providers request payer approval prior to rendering medical services. As we are all likely aware, this process can be inefficient and even costly to patients. Most importantly, it is another hurdle that can delay necessary medical treatment. Apparently, “[t]he interminable delays and back-and-forth make prior authorization the top cause of physician burnout.” So how does the proposed rule improve this system? Basically, the prior authorization improvement mirrors the rest of the rule by improving communication and coordination between providers and payers regarding the prior authorization process.
As a proposed rule, it is now in the notice and comment period. Any interested member of the public can submit comments to the rule. If you desire to send a comment for CMS to consider, you must submit it by 5:00 p.m. on January 4, 2021. You may submit electronic comments on www.regulations.gov referring to file code CMS-9123-P.
We hope this “theme” provides you with an enticing overview of CMS’ proposed rule. If you have questions regarding this blog post or how the proposed rule may impact your healthcare business or practice, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, firstname.lastname@example.org. You may also learn more about our law firm by visiting www.hamillittle.com.
*Disclaimer: Thoughts shared here do not constitute legal advice.