Payers with Medicare Advantage, Medicaid, CHIP and Individual Qualified Health Plans
offered on the federal exchange lines are required to create a 3rd party development
gateway.
This means that health plans have to enable access on-demand to member data through apps.
Payers must share all maintained data from January 1st, 2016, onward securely with members
upon request.
Does this include clinical data?
Yes.
All of this data access has to meet the one-day rule.
Meaning that data has to be available for access within one day of it being created
or received by a payer.
The compliance deadline for the interoperability rule is January 1st, 2021, and the enforcement
date is July 1st, 2021.
We recommend you consult with your legal team to understand the compliance and enforcement
implications.
This rule will have impacts across a plan's organization.
Let's take a look : To make data accessible on-demand, IT Teams
must • Identify, locate and map the required
data they "maintain" • Orchestrate data in a hub or repository
in preparation for sharing.
• Apply privacy, consent and security requirements to the data and access.
• And, deliver data through an API gateway For teams like customer service and enrollment,
the rule will require existing processes to be revamped and new processes to be launched.
And the rule will, in effect, force plans to share the "blueprint" of what differentiates
them from their competition.
But payers can capitalize on this opportunity by thinking beyond compliance to take advantage
of the rule, using data access to reduce friction, improve quality and lower the cost of care.
So, what are plans doing now?
Local and Regional plans, are striving for compliance at affordable costs and working
to leverage data integration with hospital systems to improve care quality.
To meet that goal they are: • Identifying data and the architecture
for sharing • Orchestrating data
• Applying their privacy, consent and security policies
• Delivering access through an API • Automatically analyzing historical data
to improve utilization and care management • Sharing data with regional providers to
improve patient outcomes • Reducing IT expenses by eliminating point-to-point
integrations Finally, a national plan is implementing its
"beyond compliance" strategy by gaining consent early to access member data from previous
payers.
They are: • Developing apps to acquire member consent
• Automatically authorizing care based historical data
• Applying care management at enrollment to reduce medical costs
• And, understanding patient acuity to improve ratings
Cognizant has been investing in interoperability since 2018 to help health plans strategically
achieve interoperability, with our purpose-built SaaS interoperability product suite, over
600 employees trained in the HL7 FHIR standard and interoperability advising, implementation
and business alignment services.
You can learn more about healthcare interoperability by visiting cognizant.com