3 Myths about CMS Final Rule Implementation — Debunked

May 18, 2021 Bob Tisone

The Centers for Medicare and Medicaid Services (CMS) is set to begin enforcing the Interoperability and Patient Access Final Rule starting July 1. While there’s still time to finalize and execute plans, the question looms: How will Medicaid, Medicare and other government payers facilitate interoperability with the least disruption to operations and patient care?

Right now, it’s more important than ever for the entire healthcare ecosystem to improve the care management process and reduce overhead costs. The Final Rule presents a unique opportunity to leverage the latest information exchange technology standards using Application Programming Interfaces (APIs) to drive value through greater (and mandated) access to patient health data.

The Final Rule requires CMS-regulated payers to make health information more easily available to patients by leveraging APIs and Fast Healthcare Interoperability Resources (FHIR) standards. It focuses on driving interoperability and patient health data access for health plans to create better immediate and long-term outcomes.

This is great news on paper (and in reality, too), but for many healthcare payer organizations including government health plans, it’s easier said than done. With the clock ticking, some government payer organizations are finding themselves better prepared than others to comply.

Here are three of the top concerns we’ve been hearing from our government payer clients and contacts within the healthcare ecosystem. We’re calling them “myths” because there are clear ways for healthcare payers to overcome them and ensure compliant, timely interoperability implementations.

1) Complying with CMS Final Rule will be costly.
The COVID-19 pandemic has had a broad-sweeping financial impact across the healthcare sector, with payers facing financial challenges brought about by a decrease in the insured population due to unemployment — and therefore reduced premium collection. They face ongoing financial hurdles as some members have delayed care while their health is deteriorating, conditions that can plausibly lead to future claims emerging at higher levels than originally estimated.

While government healthcare payers work to conserve funding now, it’s important to understand that Final Rule compliance is being largely funded by CMS — with Federal financial participation (FFP) available at 90% of expenditures for the design, development, installation or enhancement of a mechanized claims processing and information retrieval system, if the system is approved by the Administrator. And even though July 1 is the date for planned enforcement to begin, states can continue to receive that 90% federal funding match as long as they’re showing good faith efforts on the journey to interoperability.

Further, payers can greatly minimize the financial implications of compliance by working with a trusted provider in the healthcare space with experience in working with APIs and creating custom applications. While no two applications are exactly the same, many of the core building blocks are the same and a seasoned partner can work with payer organizations to deliver exactly what their members and providers expect in compliance with all standards and regulations.

2) Implementing interoperability will disrupt existing staff and operations.
We’ve found that many of our government payer clients are surprised to learn that interoperability apps really can be implemented in 4-6 weeks (start to finish) with minimal business disruption. Partnering with an independent vendor that knows the Medicaid industry and has a deep understanding of payer data is the best way to ensure proper and speedy mapping of your data to FHIR standards without any impact on your other data and systems. With a modular approach to systems (and systems integration), your data and systems stay clean and your existing staff and operations get the benefits of a “plug and play” implementation with greater ability to share and access data exactly as it’s needed or required.

In addition, an outsourced SaaS solution is ready to go “out of the box” with zero ongoing tech stack to manage.

3) Building a custom interoperability platform in-house will ensure the best results.
Regarding that tech stack you don’t want to manage (see #2)...

In our experience, a State Medicaid Agency building their own solution to support this type of requirement is counterproductive. You wind up going down a long path to spec, build and maintain a solution that can generally operate as a “set it and forget it” entity. Because it’s API based and lives in the cloud, a custom SaaS implementation gives you greater flexibility to quickly rollout the functionality you need — while not having to worry about future upgrades.

The right SaaS partner will manage all upgrades for you, making it future proof on a separate platform that’s fully integrated with your environment. Quick, easy, done.

The bottom line
Healthcare interoperability is good news — for patients, healthcare providers and payers including Medicaid and others. Through greater digital adoption, the healthcare industry will take leaps forward, finally realizing the decades-old vision promised by EHRs. From getting data more quickly into the hands of members to mitigating cases of Fraud, Waste, and Abuse, complete digitization empowers more people to get engaged and can have far-reaching impacts on population health, utilization, the cost of patient care, member service and support costs, and much more. 

The quickest path to compliance and moving along the journey is first debunking the myths that it has to be a costly, resource-intense initiative. Instead, healthcare payers should seek out time-tested expertise and technology that will help them minimize implementation challenges while accelerating the future of data access and patient care.

Learn how Conduent’s Healthcare Interoperability Solutions can quickly bring your organization into compliance now. It’s not too late to get started!

About the Author

Bob Tisone

Bob is the Vice President of Government Healthcare Sales and Business Development with Conduent. He has 20+ years of experience serving in and for the Public Sector. Bob and his team support Conduent’s Government Healthcare mission by providing solutions that help government agencies enable critical and essential health services.

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