Understanding the New CMS Proposed Ruling and the Importance of Interoperability

On December 6th, 2022, CMS released a proposed Federal Rule that introduced two new interoperability measures and expanded the scope of the Patient Access requirements and completely overhauled the existing Payer to Payer requirements.

While the regulation is still currently in proposal, the core themes can be summarized simply as more FHIR®, more eligible data recipients, and more data. 

  • First, all data exchanged in support of the CMS interoperability regulations must be done via a FHIR API, and typically within one (1) business day of the request or the date the data becomes available. 
  • Second, in addition to making data available to members via the Patient Access API, impacted payers must also make data available to the member’s current and/or concurrent payers via the Payer to Payer on FHIR Exchange, and to their in network providers via the Provider Access API and the Prior Authorization Resources, Documentation, and Decisions (“PARDD”) API.  

Preparing for New Healthcare Data Requirements

So what does this mean for the healthcare technology community right now? What are the key takeaways we can determine from this proposed ruling? 

While the proposed regulation still leaves many questions unanswered, there are some pertinent takeaways that can be gleaned. First and foremost, it is abundantly clear that, in the eyes of CMS,  the future of data interoperability is FHIR. The power of interoperable data comes when you go beyond just moving data around to actually making use of that data to achieve improved outcomes. Exchanging data from one system to another is a necessary component of interoperability, without the ability to standardize the data into a consistent format, the utility of that data is materially reduced. While FHIR will be required for CMS compliance purposes, the value of FHIR spans far beyond the need to check a box, and can materially improve, and reduce the costs of, the daily operations of not just health plans, but all organizations across the care continuum.

The other clear take away from the proposed regulations is that FHIR is here to stay and if you don’t know what it is or how to utilize it in your healthcare interoperability strategy, the time to get literate is NOW. While 2026 feels far away, there are steps you can be taking right now to realize the value of FHIR. 

Additionally, while the value that third-party health IT, such as EHRs, has provided in terms of data aggregation over the course of the last few years is truly remarkable, health plans are far better equipped than providers to play that role for the foreseeable future. While over the course of care, a patient can see a handful of providers at any given time, the relationship between the patient and their health plan tends to be more consistent, stable, and long-term, making the payer uniquely positioned to be the data hub, rather than just a spoke.

Successfully implementing this rule will require an entirely new approach to getting and using data eclipsing today’s silos of incumbent EMRs and current claims processing. What is needed are powerful ways to capture clinical and claims data, make that data fully computable by using the same standard, and then allow connectivity and access to such data not just to incumbent providers and payers, but to ANYONE offering digital services to patients. 

Put simply, we are 1upHealth, and we are here to be your trusted FHIR platform and strategy partner. To learn more, watch our new CMS proposed rule webinar.

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