The Standard

Join the Webinar Highlighting MCG Health’s Prior Authorization Journey and Da Vinci’s Two New Use Cases for 2021 on Wednesday, February 24 from 4:00 - 5:30 pm ET.

Healthcare organizations increasing their exposure to value-based care find many tasks complicating the transition, and reducing the burden of those changes is key to thriving under new reimbursement schemes.

New payment approaches incentivize both payers and providers to become more efficient, and that means reducing the number of manual interventions in exchanging data. In addition, value-based care is uncovering new reasons to make information more easily available, to bring new efficiencies to the system.

Examples of these capabilities will be featured in the HL7 Da Vinci Project’s Community Roundtable on February 24. The title for the event is "What it Takes: Learn about MCG Health’s Journey to Help Reduce Prior Auth Burdens and Discover New Da Vinci Use Cases."

The upcoming roundtable will offer an inside understanding of the 18-month effort at MCG Health to advance the use of the HL7 Fast Healthcare Interoperability Resource (FHIR®) standard in solutions that support burden reduction in facilitating the prior authorization process.

The Centers for Medicare & Medicaid Services (CMS) released the much-awaited Interoperability & Patient Access Rule in March 2020. The objective is to reinforce this rule by further improving health information exchange and obtaining member health records at a single location to reduce burden on payers, providers and members.

The enforcement date for this rule is January 1, 2023, and will be applicable to Medicaid programs, the Children’s Health Insurance Programs (CHIP) and Qualified Health Plan (QHP) issuers on the individual market Federally Facilitated Exchanges (FFEs). However, it will not be applicable to Medicare Advantage (MA) plans.

The CMS proposed rule will include policies to enhance the current Application Programming Interfaces (APIs) from its interoperability rule such as patient access API and payer to payer API. There are a few new APIs and requirements proposed to improve the overall prior authorization process.

Report from Virtual FHIR DevDays 2020 on HL7 Da Vinci Project Use Cases

Developers are fine-tuning ways to use the HL7 Fast Healthcare Interoperability Resource (FHIR) standard to reduce communication challenges and decision impediments between providers and payers.

Working on use cases involving coverage and burden reduction, the HL7 Da Vinci Project is refining early versions of standards and developing implementation guides for value based care (VBC). Speaking to more than 150 attendees during the virtual HL7 FHIR DevDays event, Dr. Viet Nguyen, Da Vinci Project Technical Director, noted that the coverage and burden reduction use cases are intended to address workflows around provider-payer interactions. FHIR implementation guides are then created based on a set of use cases. 

Coverage Requirements Discovery

One use case, Coverage Requirements Discovery, gives providers real-time access to payer approval requirements, documentation and rules at point of service to reduce provider burden and support treatment planning. In its essence, this would answer a provider’s question about whether a procedure or treatment needs a prior authorization from a payer. The aim is to use CDS Hooks to supply an answer to a clinician posing the request within his or her workflow. Work is continuing on developing an implementation guide for this use case.