The CMS rule on advancing interoperability and improving prior authorization (CMS-0057-F) sets a foundation for future policymaking. As payers embark on this compliance journey, it is critical to reassess and analyze their current systems and processes with intentionality. By aiming to not just meet, but to exceed the requirements, payers can maximize the benefits of establishing three new APIs and enhancing the already implemented patient access API. In a recent HIT Policy Pulse webinar, we revisited the above compliance process, previously introduced when the rule was still proposed. To make this complex topic more approachable, we have broken it down into a series of brief blog posts. Given that future rules will build upon the usage of these required APIs, this initial implementation will serve as a crucial foundation for future compliance. This blog will explore the initial steps of compliance, ensuring that payers lay a solid groundwork that will support future regulations built on these initial API requirements. While we developed this graphic in anticipation of the the CMS-0057-F rule, these phases really could apply to any big compliance or implementation effort.
This rule, pivotal in its scope and impact, necessitates a meticulous understanding not only of the requirements but also of the payer's current position relative to these new standards. Therefore, the "Assess and Analyze" phase is foundational—it involves a comprehensive review of the existing systems, processes, and personnel capabilities against the mandates. It is during this phase that payers must take stock of their current capabilities and identify any gaps that might impede compliance. This includes pinpointing shortcomings within their technological infrastructure, operational workflows, and workforce competencies.
Furthermore, it's not just about identifying the gaps—it's also about strategizing on how to bridge them. This could involve seeking out strategic partners or leveraging external resources to fortify the payer's capabilities. By doing so, payers can ensure they not only meet the bare minimum for compliance but also enhance their overall operational effectiveness.
Transitioning into decision-making, payers must weigh their options on how best to approach these complex implementations. It's a pivotal juncture where the paths laid out in the analysis phase are evaluated, and concrete plans are formulated.
However, beyond mere compliance, there's a broader strategic dimension to consider. For instance, with the CMS rule mandating the establishment of new APIs, payers can think beyond the rule itself. These APIs, while created to satisfy specific regulatory requirements, can be harnessed to support wider business objectives. These additional functions could be programs leveraging APIs to improve patient engagement. APIs could also be used to automate other data reporting functions to free up time for providers. Payers should explore how the infrastructure built for compliance can simultaneously be utilized to drive other business use cases, thereby not only fulfilling regulatory obligations but also propelling the organization forward strategically.
In essence, the "Assess and Analyze" phase is about setting the stage for informed, strategic decision-making. By thoroughly understanding the new CMS rule and the payer's relation to it, as well as identifying and addressing gaps with precision, payers can lay a solid foundation for compliance and beyond. It's a phase that demands attention to detail and foresight—qualities that are essential in the ever-evolving landscape of healthcare IT.
While the road to meeting new healthcare IT regulations such as the CMS rule on interoperability and prior authorization may seem daunting, the "Assess and Analyze" phase is a critical step that sets the tone for your organization's success. It’s about more than just ticking boxes for compliance; it’s an opportunity to realign your IT infrastructure and processes with broader business objectives. However, achieving an objective, comprehensive assessment to determine the best path forward is not always straightforward. It requires expertise and an external perspective to ensure that nothing is overlooked. POCP has helped several national & regional payers with objective assessments and strategic recommendations. If your organization needs help navigating this complex landscape with clarity and confidence, we can help. Reach out to me at brian.dwyer@pocp.com for expert guidance to illuminate the most strategic path forward for your organization. Let's connect, evaluate, and advance your healthcare IT capabilities together. Be sure to register for our next HIT Policy Pulse webinar where we'll dig into pharmacy interoperability and advance clinical practice.
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Is 2024 the Year of the Pharmacist?
Harnessing the Potential of Pharmacy Interoperability & Advanced Practice
May 29, 2024
12 - 1 PM ET