Setting Authorizations on FHIR: Improving the Patient and Provider Authorization Experience Through Greater Interoperability

CMS has recently proposed a rule intended to increase interoperability and transparency in prior authorization (PA).

The utilization management (UM) process typically begins with a referral from a doctor or other healthcare provider. The UM team then reviews the referral and assesses the medical necessity of the service and patient’s eligibility for coverage. Once approved, the UM team reviews the appropriateness and quality of the care provided, and makes recommendations for care that is clinically appropriate, cost effective and meets established standards. These UM teams also monitor the quality of care and the outcomes of care provided to ensure the best outcomes for the patient.

In practice, this back-and-forth can be cumbersome and involves quite a few manual workflow steps. And much of it is hidden from the view of providers, patients, and other stakeholders.

The proposed rule – entitled Advancing Interoperability and Improving Prior Authorization Processes –applies several of the leading approaches to health interoperability to health plans serving a wide range of CMS beneficiaries:

  • Medicare Advantage organizations
  • State Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service programs
  • Medicaid managed care plans and Children’s Health Insurance Program CHIP managed care entities
  • Qualified Health Plan issuers on the Exchanges

Provisions in the rule encompass leading approaches to health data interoperability, including the implementation of Fast Healthcare Interoperability Resources (FHIR). FHIR is an expansive, international health data standard for which AssureCare has developed a range of services to support inbound and outbound exchange of clinical data.

Key elements of the rule include:

  • Addition of prior authorization to the FHIR Patient Access API: patient claims and encounter data (excluding cost information)
  • Certain payors must exchange and maintain certain patient health information to comprise a longitudinal health record for the patient (FHIR API is encouraged, but not required)
  • Require that plans exchange patient data when a patient changes health plans (with patient opt-in) — data would include claims and encounter data (excluding cost information), and prior authorization requests and decisions
  • If a beneficiary has concurrent coverage with multiple plans, the plans must make that beneficiary’s data available to each other at least quarterly
  • Plans must build and maintain a FHIR API (PARDD API) that would automate the process of prior authorization and document exchange

CMS also issues several requests for information (RFI) on adopting standards and methodologies to accelerate adoption.

This intersection of Service Authorization and interoperability – and, in particular, use of the FHIR standard – represents a sweet spot for us as a company. In recent years, there have been an array of enhancements made to MedCompass to broaden support for FHIR resources across patient health record, pharmacy, claims and a variety of encounters.

As CMS acknowledges in its rulemaking, a FHIR-based process for submitting and processing authorization requests would have numerous benefits, including:

  • Improved understanding and satisfaction for health care consumers, particularly when transitioning between plans
  • Support for price and service transparency from plans to patients and providers
  • Better coordination between plans
  • More complete patient health record keeping, with application to Patient Health Record (PHR) portals and other third-party integrations
  • Significantly higher uptake of SA automation and workflows
  • Improved turnaround time across workflow

Interested in learning more about MedCompass and how our platform can meet your needs? Learn more here.

This blog is co-authored by Joshua Shreve, senior technical product manager at AssureCare.

Koen Brown

RN, MSN, CCM, Project Management Director, AssureCare