The CMS Rule 0057 mandates that health plans develop and support FHIR-based APIs to facilitate FHIR-Based ePA. Whether this investment merely ensures compliance or unlocks broader benefits such as improved provider experience, enhanced efficiency, and streamlined operations depends on strategic planning and collaboration rather than cost alone
To assist health plans in addressing these critical aspects, Healthcare Information Systems shares insights based on their experience with early adopters. Below are five frequently asked questions (FAQs) and expert recommendations to optimize implementation and maximize returns.
Q1: What’s needed to connect my plan’s back-office coverage and utilization management systems to the required FHIR APIs?
A smart API broker and data integration engine is essential. Health plans must query multiple systems to determine prior authorization requirements, including member eligibility, policy coverage, and provider status. Additionally, adjudicating prior authorization submissions, especially when implementing FHIR-Based ePA, involves a combination of proprietary medical policies, licensed rules, and delegated vendors.
Since many legacy systems do not fully support FHIR, an API broker that automatically routes requests to the appropriate back-office system is necessary. Furthermore, a data integration engine enables the bi-directional flow of normalized data, ensuring compatibility across all platforms involved.
Q2: Are there best practices for translating medical policies governing prior authorization into machine-readable language?
Yes, prioritizing high-impact procedures can accelerate return on investment (ROI). Converting all medical policies into machine-readable formats is an extensive, ongoing process. However, prior authorization requests typically cluster around a limited number of procedures. By identifying these high-frequency cases, health plans can:
- Improve turnaround times for a significant portion of authorization requests.
- Reduce manual interventions that contribute to administrative burden.
- Enhance provider and member satisfaction by expediting decisions.
Focusing on the 80/20 rule—where 20% of procedures account for 80% of requests—enables a targeted and efficient approach to automation.
Q3: How can my plan drive provider adoption of the ePA process mandated by CMS Rule 0057?
Ensuring that the ePA solution is reliable and time-saving before launch is crucial. While CMS-0057 mandates that providers test the new FHIR-based prior authorization process, continuous usage is not required. Therefore, first impressions matter—if providers encounter inefficiencies or technical difficulties, adoption rates will suffer.
Key strategies to drive provider engagement include:
- Seamless Integration: Ensure the ePA process is fully integrated into existing EHR and practice management workflows.
- Clear Communication & Training: Educate providers on how to leverage ePA capabilities effectively.
- Performance Monitoring: Address pain points quickly to enhance user experience and encourage widespread utilization.
A frictionless, time-saving experience will increase provider participation, ensuring long-term success of the ePA initiative.
Q4: Can this functionality be readily scaled to all lines of business, including commercial products?
Yes, but scalability depends on addressing three key factors:
- Transaction Volume: The system must handle high query loads while maintaining reliability and speed.
- Administrative Silos: The API broker must efficiently route queries across different systems that support various business lines.
- Policy Prioritization: Different lines of business may have unique high-impact procedures, requiring tailored machine-readable policy translation efforts.
By accounting for these elements, health plans can ensure uniform ePA implementation across Medicare, Medicaid, and commercial products.
Q5: Can AI help reduce frustration with prior authorization?
Absolutely. AI-driven solutions can enhance ePA by:
- Automating Routine Decisions: AI can process straightforward approvals faster, reducing manual intervention.
- Identifying Systemic Bottlenecks: AI can analyze workflows to detect choke points and suggest improvements.
- Enhancing Data Accuracy: AI algorithms depend on high-quality, harmonized data that integrates clinical, administrative, and social determinants of health (SDOH) data.
However, data integrity is a prerequisite—ensuring timely, normalized, and structured data is essential to maximize AI’s potential in streamlining prior authorization and advancing value-based care.
Final Thoughts: Preparing for the Future of ePA
CMS Rule 0057 represents a significant shift in prior authorization processes, requiring health plans to embrace FHIR-based interoperability, AI-driven efficiencies, and provider-centric solutions. By leveraging smart API brokers, machine-readable policies, scalable architectures, and AI applications, plans can turn compliance into an opportunity for operational excellence. Specifically, the implementation of FHIR-Based ePA is crucial for achieving this interoperability.
The key to success lies in pragmatic implementation and continuous provider collaboration—ensuring that the transition to electronic prior authorization reduces administrative burden, accelerates approvals, and improves healthcare outcomes.