Unlocking healthcare opportunities through the CMS Interoperability and Prior Authorization Final Rule
By Dr. Katherine Dallow, Vice President and Executive Medical Director of Government Strategy at Carelon Medical Benefits Management.
Exchanging healthcare information just got easier
As a physician, I know how vital it is for prior authorization determinations to be made quickly. I’m happy to report that major advances are happening right now that will yield better experiences for both patients and providers.
In January 2024, the Centers for Medicare & Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule (CMS-0057-F). For some time, prior authorization, access to electronic medical records (EMR), and fragmented health information have been pain points for everyone in healthcare. If left unaddressed, these challenges will not only compound the current lack of transparency we experience today, but they will also result in added costs and unnecessary care.
As a patient-first organization, we’re driven to advance the delivery of evidence-based, connected care to achieve affordable, whole-person health. We support the provisions of CMS-0057-F and recognize that a more efficient prior authorization process benefits everyone and prioritizes provider-patient relationships.
A 360º view of patient health
Limitations on access to information have been an ongoing challenge across the entire healthcare industry. Often, a member’s healthcare information, including data pertaining to prior authorizations, is siloed and only available to their current provider and health plan. If a member’s insurance coverage changes, when switching jobs for example, prior authorization history may not be readily available to their new health plan or provider — or to the member themselves.
CMS-0057-F represents the next chapter in an evolving information landscape that began with the implementation of EMRs. The new rule requires payers, providers, and entities such as Medicare Advantage and state Medicaid programs to use Fast Healthcare Interoperability Resources (FHIR)-based Application Programming Interfaces (APIs) to access health records, facilitate speedier access to data, and share patient data securely within existing HIPAA mandates. The new requirements will improve the exchange of health information between providers, payers, and patients, creating a 360º view of members’ care.
Industry leaders in tech-enabled prior authorizations
At Carelon, we have already built a solid reputation as a pioneer in using technology to improve prior authorizations. In 2004, we implemented the industry’s first online provider portal for prior authorizations. The industry quickly followed our lead.
Because of this and other innovations, we are already in compliance with many aspects of the Final Rule. Today, 93% of the requests that we receive are closed within 48 hours.*
Our standards-based API was implemented several years ago to give members access to their data and to optimize information flow with health plans. With this infrastructure already in place, we are now working on information exchange between providers and payers.
Better connected care for members —
less administrative work for providers
Faster prior authorization and facilitated information exchanges mean a better care experience and a more complete picture of members’ overall health. If members switch providers — or insurance plans — these new regulations help to ensure that healthcare information is secure and accessible to new providers. Our systems are designed to better serve patients and provide a more seamless transition for those who are already receiving treatment or who have already received approvals for procedures.
Key components
CMS-0057-F streamlines prior authorization by:
- Reducing decision times: For standard requests, the decision timeframe is seven calendar days. Expedited requests are handled within 72 hours.
- Facilitating access to relevant patient data: Providers can access the information they need within one business day. This includes claims, clinical details, and prior authorization data.
- Streamlining payer-to-payer data exchange: To promote care coordination, payers will transfer health data when members transition between insurance plans through secure, FHIR-based APIs.
- Increasing transparency: Payers will publicly report prior authorization metrics annually, which enhances transparency and facilitates informed decision making.
Our commitment to you
The CMS Interoperability and Prior Authorization Final Rule supports our efforts to simplify how healthcare information and prior authorization data is shared across a member’s healthcare journey. With the changes outlined in CMS-0057-F, we are paving the way for more seamless, connected care.
Member, provider, and health plan benefits
- Faster access to care and a more seamless experience for members
- Less administrative work for providers and more time with patients
- More appropriate care
Learn more about Carelon Medical Benefits Management or contact us.
About the author
Dr. Katherine Dallow is Vice President and Executive Medical Director of Government Strategy for Carelon Medical Benefits Management. She is an internal medicine physician by training, with extensive clinical, administrative, and leadership experience.
See healthcare from our perspective
* Internal data, 2024.
The benefits of comprehensive Palliative Care for patients and caregivers
Our Palliative Care provides an extra layer of compassionate support designed to ease the difficulties of living with a serious illness. This specialized care offers personalized goals, comprehensive disease management, symptom control, and unwavering support for you and your caregivers, helping you live your best life while saving on medical expenses.
Whether you have a serious illness or care for someone who does, Palliative Care can help manage the complexities and costs of whole-health care. Choosing this kind of care may sound complicated or scary, but it's not. Palliative Care provides an extra layer of comprehensive support to develop personalized goals and care plans that help ease the stresses of living with a serious illness.
What is Palliative Care?
Palliative Care is medical care for patients with complex conditions or a serious illness, at any stage of their disease or condition. Common diagnoses among Palliative Care patients include advanced cancers, heart failure, chronic obstructive pulmonary disease (COPD), asthma, renal disease, liver disease, cerebrovascular accidents, and other neurologic illnesses, including stroke. A typical Palliative Care plan works alongside your primary medical treatment plan and can include:
- Disease and symptom management, including controlling your pain.
- Coordinated in-home care and support services.
- Communication with family members and other caregivers.
- 24/7 support either virtually or by phone.
- Reduced costs by preventing hospitalizations and emergency room visits.
- Advance care planning and support for end-of-life treatment decisions, if applicable.
Unlike hospice care, which prioritizes comfort, symptom management, and quality of life for those with a terminal illness, you don't have to stop curative treatment for your illness if you choose Palliative Care. You also don't need to have a terminal illness or be approaching the end of life.
You or your loved one can continue to receive medical treatment to manage symptoms. You can even receive treatment to cure your illness.
Palliative Care is for anyone who needs an extra layer of support as they navigate their illness. It can begin as early as the day you are diagnosed, and it can continue throughout your entire healthcare journey.
How Palliative Care improves your quality of life
No one needs to tell you how complicated and frustrating it is to manage your illness. If you're a caregiver, you see firsthand how difficult daily living can become, both physically and mentally.
Chances are you often juggle many doctor visits, medicines, and care instructions. There are a lot of little details that need to be remembered and instructions that need to be followed. Along with that, you experience the range of emotions that come with navigating complex condition management. Serious illness can also affect you financially, because it's common for people with these conditions to end up in the hospital or emergency room.
The goal of Palliative Care is to improve your well-being across all these areas of life. After you become a Palliative Care patient, you'll receive comprehensive, wraparound support throughout your treatment journey. A personalized care plan will focus on your specific symptoms, challenges, and goals, and you’ll have an interdisciplinary team that coordinates your care.
A compassionate care team that meets you where you are
Depending on your illness and the services you need, your care team may include doctors, nurses, nurse practitioners, social workers, care coordinators, and other specialists, such as nutritionists or therapists. You can also keep your current doctors.
Your care team works with you, your current doctors, and any caregivers you may have to address your medical, social, and emotional needs. You'll receive appropriate care, when and where you need it — whether that's at home, in specialized clinics, or at inpatient or outpatient locations.
You’ll also have the option of 24/7 access to your care team through telehealth with a phone or video call. These virtual visits can be particularly useful if you have a busy schedule or if your illness gets in the way of safe or comfortable travel.
Providing support for caregivers
If you care for someone with a serious illness, you know that managing someone's care can often feel like a full-time job. Even if you're organized, it's normal to feel overwhelmed. Caregiver burnout happens, and you're not alone if you feel this way. According to a report on caregiving in the United States by the National Alliance for Caregiving (NAC) and the American Association of Retired Persons (AARP) :
- 31% of family caregivers have difficulty coordinating care.
- 21% of family caregivers report their own health is fair or poor.
- 23% of Americans say caregiving has made their health worse.
When loved ones choose Palliative Care, caregivers also get the help they need to take better care of themselves. Caregiver support should include counseling services, education, and resources about your loved one's illness and treatment, and shared decision-making and collaboration in your loved one's care.
Care throughout your health journey
The best time to start Palliative Care is when you are diagnosed with a serious illness. Why does it make sense to start so soon?
Serious illnesses can take a huge physical, mental, and financial toll on you and your caregivers. Starting palliative care early can help you reduce or avoid some of the stress associated with your condition. If your illness gets worse, your Palliative Care services can shift to match your changing needs. Your care team can help you with advance care planning and end-of-life treatment decisions if needed, or help you transition to hospice care if that becomes necessary.
At Carelon, we provide Palliative Care with a goal of improving your holistic quality of life and well-being. We are the nation’s largest provider of nonhospice, home-based Palliative Care, offering in-person and virtual care in nearly all 50 states. Our approach provides specialized, coordinated care for anyone with a serious illness, matching our high-quality services and care to your unique needs. You’ll also receive care services for disease management, symptom control, and behavioral support, while still receiving medical treatment to cure your illness. This provides an extra layer of whole-health support to you and your caregivers and can prevent the need for more intensive services like emergency room visits and inpatient hospitalizations.
Now that you know more about this form of specialized care, you may realize it's a good time for you to learn more. To get started, talk to your doctor about a referral. There’s no need to wait. Discover how Carelon’s experienced and compassionate Palliative Care can help you feel better while improving your health.
