Maximizing Your ROI While Meeting CMS Interoperability and Prior Authorization Requirements

The APIs are the Easy Part

What are your organization’s top strategic investments for the coming year? According to a recent Gartner survey, 46 leaders from various US payers ranked quality improvement, data and analytics, behavioral/mental health, and risk adjustment optimization as their most important initiatives. But those same leaders identified regulatory shifts as the top factor driving enterprise decision making. Indeed, regulatory shifts was the only such factor considered at least “somewhat important” by all respondents and “very important” by nearly three-quarters of surveyed leaders.¹

Unfortunately, complying with new regulatory requirements is often seen as a distraction from “more important” organizational initiatives. In some cases, though, such mandates align well with business priorities and provide the necessary urgency to move key initiatives forward. Approached from the right perspective, new regulatory requirements can be harnessed to put in place infrastructure and business processes that will strengthen the enterprise for years to come. The CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F, released in January 2024, represents just such an opportunity for health plans.

This whitepaper walks through key aspects of CMS-0057-F, including information sharing with other plans, in-network providers, and members and electronic prior authorization (ePA). It discusses associated technical and operational requirements, impacted workflows, timelines, and resulting opportunities for performance improvement. We trust it will be a resource shared across your organization to help understand, plan for, and capitalize on this important advancement toward value-based care.

Topics covered in this document include:

• Rule Scope
• The Access APIs: Securing Outsized Returns on Sunk Compliance Costs
• ePA: Minimizing Inefficiency and Provider Abrasion
• Extending Value Beyond Impacted Payers
• Key Questions for IT and Operational Leaders
• What Next?

Note: This document is informational only and does not constitute legal advice.

¹ - Bishop, M, 1Q24 U.S. Healthcare Payers Enterprise Benchmarks: Priorities and Technology Deployments, Gartner, 1 March 2024- ID G00809883