CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Compliance
What is Burden Reduction Rule?
As a healthcare provider, imagine the frustration of trying to order an MRI for a patient experiencing severe, unexplained headaches. You encounter multiple obstacles, such as delays in patient care due to the administrative burden of obtaining insurance authorization, lengthy response times from insurance companies, and the risk of not being reimbursed for the MRI if authorization is denied. These challenges not only impact your ability to provide timely care but also put your patient’s well-being at risk.
That’s exactly the problem statement what CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) released in January 2024 intend to solve, by reducing administrative burdens for providers and payers (Medicare Advantage and Part D plan sponsors) and is popularly known as “Burden Reduction Rule". The rule enhances certain policies from the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) and adds several new provisions to increase data sharing and reduce overall payer, healthcare provider, and patient burden through improvements to prior authorization practices and data exchange practices.
Download this overview today to learn how XYRAM helps payers meet the requirements of the CMS-0057-F regulation, streamline prior authorization processes, and reduce administrative burdens.
Frequently Asked Questions
Adhering to the CMS 0057-F final rule is critical for plan sponsors to avoid penalties and maintain their ability to participate in the Medicare Advantage and Part D programs. Non-compliance can lead to significant financial, operational, and reputational consequences. Therefore, plan sponsors must implement robust compliance programs and continually monitor their adherence to CMS regulations to avoid these penalties. Additionally, payers will benefits from better cost management, enhanced compliance, improved data insights, and strengthened provider relationships.
Yes, CMS is requiring all payers (excluding QHP issuers on FFE) to send prior authorization decisions within 72 hrs for expedited or urgent requests. Timeframe for standard requests is seven calendar days.
Unlike for payers, the CMS-0057-F final rule does not explicitly list financial penalties for provider organizations that do not comply with its provisions. However there are several potential repercussions for non-compliance like Negative impact on MIPS score, Difficulty in participating in Value based care models, and indirect finacial impact due to denied claims, delay in patient care, delayed claim payments and overall patient dissatisfaction .
Yes, a new measure “Electronic Prior Authorization" has been added for the MIPS Promoting Interoperability performance category and the Medicare Promoting Interoperability Program.
No, the prior authorization requirements in Prior Authorization Final Rule (CMS-0057-F) do not apply to drugs.
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