If 2021 is any indication, 2022 promises to be an eventful and productive year for MHDC. We closed 2021 with partnership agreements with the Lown Institute, 1upHealth, Blue Cross Blue Shield of Massachusetts (BCBS), and the New England Baptist Hospital (NEBH). These agreements will provide our members and community with the health data services that help make interoperability less complicated and more valuable.
The Lown Institute will contribute their measures of hospital and health system equity, low-value care, and outcomes to the case-mix analytics in our Spotlight analysis service. 1upHealth will work with us to offer MHDC CodeMap, a code translation service that enables healthcare organizations to convert their health data into the codes necessary to support exchange, coordinate care, manage risk, and promote health equity. With BCBS and NEBH, we will be launching an open, standards-based prototype of digital prior authorization that will identify the critical steps and missteps that organizations must understand if they’re to automate successfully.
We also expanded our events in 2021 - nearly forty in total between executive forums, community webinars, and Vantage Point interviews - to address health data management and its many touchpoints across the industry and in the lives of individuals. Our hosted events have grown to address essential topics in consumerism, behavioral health, telemedicine, interoperability, advanced technologies, privacy and consent, regulations and compliance, public health, equity, social determinants of health, and more.
So, what will constitute a successful 2022 for MHDC?
First, we will deliver on the agreements we have signed in 2021. Lown measures add equity insights, information on the value of care, and clinical outcome data to Spotlight. Current and future users will want to round out their strategic analyses in a way that makes this data actionable - for example, it’s one thing to know that your organization’s structure does not reflect the composition of your community and quite another to understand what your organization must do to change that.
Code mapping is an invaluable tool to add to a payer’s or provider’s kit, not just to comply with formats required for interoperability internally and with partner organizations, but to ensure that it's done using standards everyone understands in the most economical way possible. Our service will provide this to the community at large.
Doing electronic prior authorization well requires following a technically proven cookbook and close collaboration between IT, operations, and clinical care. Together with our partners in the prototype project, we'll figure out that cookbook and the right way to collaborate in our prototype project.
Second, MHDC will focus more in 2022 and beyond on the person, the patient, the member, and the family. The emerging patient-centered health economy cannot function unless health data governance is delegated substantially, if not wholly, to the individual. In the US, 334 million residents’ health data is distributed across a million physicians, 6,000+ hospitals, and nearly a thousand health insurance carriers – private and public. Not all current data and interoperability regulations touch all of them, especially payer regulations as only 91% of the population has any type of health insurance. Starting with clinical and claims data but quickly moving to demographic and equity-related data sets, health plans and providers will need the continued engagement of the member-patient community to supply, ratify, and engage with the data that describe them. At MHDC, we expect these industry-consumer collaborations to increase in 2022 and beyond.
Finally, MHDC will make it easier for everyone in the health data community to work with us. Our events, memberships, and subscriptions present an array of services and benefits that many more in our community would attend, use, and support if we made working with MHDC less complicated. In 2022, we will simplify and streamline the MHDC membership process and fee structure to help individuals and organizations in Massachusetts and beyond.
We have an exciting and challenging agenda for the year. We look forward to engaging with you to move from plans to reality.
Denny Brennan, Executive Director
Please let us know what you think of our newsletter at firstname.lastname@example.org and look for our next issue. Thank you for your continued support and participation!
Meetings through January:
Want to learn more about any of these meetings? Email email@example.com
Join us for our upcoming webinar:
Own Your Healthcare Experience: An Open-Source Path presented by Juhan Sonin of GoInvo on January 11 from 10 - 11am.
Missed any of our webinars in 2021? Click here to see what you've missed!
Interested in holding an MHDC webinar or have an interesting topic you'd like to present? Contact us at firstname.lastname@example.org
January 2022 Regulations: Payer => Payer Exchange
The Payer => Payer exchange as mandated in the May 2020 Interoperability rule from CMS is scheduled to go in effect on January 1, 2022. This rule requires payers to send clinical data within USCDI v1 related to events with dates of service on or after January 1, 2016 to another payer at the patient's request so long as the patient was a beneficiary of a plan with that payer within the five years immediately before the request was made. The rule recommended using FHIR for this exchange but did not require it.
CMS has decided to delay enforcement of this requirement pending new final rules that outline a more standardized exchange format. We anticipate a requirement to use FHIR, particularly as this data is already available in FHIR formats for the Patient Access APIs (the frozen Prior Authorization rule had this requirement in place). It also permitted an additional bulk FHIR option allowing payers to collect requests from new members during their onboarding process and send them en masse after the close of each open enrollment period (or at the end of Q1 each year for plans without open enrollment periods). This option is more complex and involves additional technical, process, education, and support cycles from payers. We do not expect it to be required at this time, although it's always possible. See our article on 2022 predictions for more on this topic.
January 2022 Regulations: No Surprises Act
The No Surprises Act was part of the consolidated budget bill passed at the end of 2020. The law indicated most of its provisions take effect on the first day of new plan years on or after January 1, 2022. Two major regulations related to the law have been released as interim final rules (IFRs), but the vast majority of clauses do not yet have corresponding regulation. In an interesting move, several major clauses are supposed to be implemented anyway in a good faith effort to meet the requirements of the law. Regulation for most of these components are expected in the future at which time adjustments might be needed for existing implementations.
Let's take a look at the various clauses of the act and what we know about enforcement of each.
Price Transparency for Care
The price transparency components of No Surprises falls into three major categories: emergency services, non-emergency services, and continuity of care.
The first IFR covered emergency services, redefining the federal definition of what constitutes an emergency service and a rule that all emergency services must be covered at in-network cost sharing for patients and these payments must be included in in-network deductible and out of pocket maximum rules for the patient.
There are several different areas addressed for non-emergency services. First, any out-of-network providers practicing at an in-network facility must be covered as if they're in-network providers. This is true for hospitals, hospital outpatient centers, critical access hospitals, and ambulatory surgery centers; urgent care centers are not currently on the list but are being considered. Visits to these facilities do not have to be onsite; telehealth counts, as does imaging or laboratory work actually performed offsite or sent offsite for evaluation but offered through the facility. It is unclear if office visits at a separate location offered through the auspices of the facility also count; there are indications they do but it has not been explicitly stated either way. Patients may sign away this right in some but not all circumstances, but doing so must be voluntary with no coercion; a partial list of bad behaviors that invalidate consent is included in the IFR.
The major component of the rules for non-emergency services revolve around cost estimates for patients. The process and requirements for these differ depending on whether the patient is insured or uninsured/self-pay (defined as choosing not to use their insurance within the regulations).
In both cases, either when a service is scheduled or at the request of a patient, a provider organization initiates the process by creating a good faith estimate (GFE) of what the services will cost. The GFE is organized around a scheduled service even if it's performed by multiple providers or at multiple facilities or both. A primary provider is responsible for gathering estimate information from all of the other providers and including it in a single GFE.
For uninsured or self-pay patients, the GFE is sent directly to the patient in a format of the patient's choosing; this is outlined in IFR 2. For insured patients, the GFE is sent to the patient's payer. In both cases this must happen within three days if a service is more than ten days in the future (or not scheduled) and one day if it's within three days of the expected date of service.
After a payer is sent a GFE from a provider they have the same time frame of one or three days to produce an Advanced Explanation of Benefits and send it to the patient/member in the format of their choice.
While not binding, estimates are expected to be in the ballpark; patients are allowed to dispute bills from any provider when they differ from the estimate received for those services by more than $400.
Both patients and out-of-network providers have the ability to dispute bills (patients) or payer payment amounts (provider) using a process outlined in the second IFR.
Continuity of care requirements cover care that's already underway when a provider and payer sever their contract and a provider moves from in-network to out-of-network. The No Surprises Act requires that the payer continue to treat this care as if it were in-network for a minimum of 90 days after the relationship is severed and the provider continue to accept both payer and patient payment at in-network rates.
Enforcement expectations for these vary; see the summary chart below for specifics.
There are a variety of patient and member services that can affect cost of services also included in the No Surprises law. There are strict new provider directory requirements for both payers and providers meant to ensure that provider directories are up to date and that, if they aren't, patients aren't responsible for bad information they contain. Providers are required to send payers updated information whenever they start a new contract, end a contract, have material changes, or if the payer requests them. Payers are required to verify the information in their provider directories at least every 90 days; if they can't verify a provider's information they must be removed from the directory. In addition, payers are required to respond within 1 business day to requests about provider or facility status. Patients relying on incorrect information gained from the directory or an inquiry cannot be penalized and services from the relevant providers or facilities must be treated as in-network in terms of cost sharing, deductibles, and out of pocket maximums.
No Surprises also has new requirements for insurance cards. Insurance cards must include a patient's major medical deductible, major medical out of pocket maximum, a telephone and website for consumer assistance, and either information about or a website containing information on additional deductibles and out of pocket maximums if they exist.
Provider Directory and insurance card clauses don't have regulations yet but are enforced to a "good faith effort to implement" level starting in January 2022.
No Surprises also includes requirements around education, notification, and promotion of its other requirements. These include requirements that payers and providers post public notices about no surprise billing and patient rights in each physical facility, provide a one page written document about their new rights to patients, and post information about patient rights on their public websites. The requirement to supply these with some basic information about the required content is covered in IFR 1 but additional information about these and possibly additional disclosures is expected in future rules.
The No Surprises Act also includes other requirements. It prohibits gag clauses or similar clauses in agreements between payers and providers that directly or indirectly prevent disclosure or access to provider-specific price, cost, or quality data. It also includes compensation disclosure requirements for insurance brokers, plan managers, benefits consultants and similar personnel.
Quick Summary of Enforcement
In summary, here's a list of what is and is not being enforced right away:
Enforced January 1, 2022 (or first plan rollover thereafter):
Not Enforced until later:
And there you have it - everything we currently know about No Surprises so it doesn't surprise you as much as it surprised us.
Electronic Prior Authorization (ePA) Initiative
This project is a prototype implementation that automates prior authorization transactions using the industry standard, open platform methods developed by the HL7 DaVinci Prior Authorization workgroup. This project will be compliant with the three related implementation guides which utilize open, FHIR based API exchange methods. This will allow payers and providers to implement a single prior authorization process and format for exchange so long as all of their exchange partners adhere to the same standards.
We are pleased to announce that we have a signed agreement with Blue Cross Blue Shield of Massachusetts and New England Baptist Hospital. We will officially kickoff the prototype project at the start of 2022.
Concurrently, we continue to participate in the DaVinci Workgroup and provide feedback and input into the work product of the final implementation guide. The focus of the DaVinci WG at this time is defining the actions and functions allowed within a PA-related questionnaire used to collect additional details regarding a specific PA request from providers at the behest of payers. Questionnaires are launched by an installed SMART on FHIR app which walks a provider through the information needed for a specific clinical scenario. Once complete, the EHR saves the questionnaire responses within the clinical and patient context for delivery back to the payer. Details about the specific actions needed to accommodate the various PA use cases will be incorporated into the relevant Da Vinci IGs once this work is complete.
For more information email us at email@example.com.
Interested in webinars and online conferences in late December and January? Here are some we recommend (they're free unless otherwise noted):
Have an upcoming event next month to suggest? Write us at firstname.lastname@example.org - no self-promotion please.
Looking Back at 2021
Looking Forward at 2022 Crossword
Looking Forward at 2022
What will 2022 bring? What will we be focusing on this time next year? The simple truth is that we don't know. Price transparency and other No Surprises Act clauses weren't on our radar this time last year but it consumed many of our cycles as we moved further and further into 2021. That said, we do know some of the items currently on the agenda for 2022 and some other things Congress, HHS, and others have said will be priorities for them moving forward. Given that, here's our best guess at what we can expect in health IT in 2022:
So there you have it - 12 predictions for 2022, some based on currently announced plans and regulations, some best guesses based on industry chatter and comments by regulators, and a couple of wilder suppositions that may or may not have any basis in reality. We'll see how we did at the end of next year. What do you think will happen in 2022? Let us know at email@example.com.
Before we go, here's a reminder of upcoming data exchange deadlines from ONC and CMS (including the CMS rule that's currently frozen, as noted by *):
And that's it, folks. Loved it? Hated it? Have an idea for next time? Send us feedback and suggestions about this newsletter at firstname.lastname@example.org or send us feedback and suggestions about anything else at email@example.com.