Interoperability, CoP, Reimbursement 2020 Rule Changes: What They Mean for You

by Justine Olsen on May 12, 2020

Doctor with Health Data MatrixThe unprecedented onslaught of COVID-19 and the strain it’s put on the medical system have caused providers to take their own unprecedented steps to combat the virus.

In light of that, the Centers for Medicare and Medicaid Services (CMS) have shown a willingness to adjust their own rules to accommodate the extraordinary circumstances healthcare providers are now living through. That’s good news for a healthcare labor force composed of professionals used to spending countless hours navigating the bureaucracy of the current regulatory setup.

But the relaxation of certain rules and increased flexibility from CMS also creates a number of questions. We’ve closely analyzed the recent developments put out by CMS, and here are some examples of how they could affect the work acute providers and case managers do every day.

Conditions of Participation and Interoperability

One of the biggest moves from CMS in recent weeks is the delay of the Final Rule mandating the admission, discharge and transfer (ADT) Conditions of Participation (CoP) as well as API policies for the Medicare Advantage program. Enforcement of the former would have applied six months after the Final Rule was ultimately issued on the CMS website in March, while enforcement of the latter was set to come at the very beginning of 2021. Each of these have received a six-month pushback, i.e. March 2021 and July 2021, respectively.

Let’s take each of these in turn, starting with the Conditions of Participation section. This rule, which is just one of the ways CMS is forcing the issue about technology interoperability, requires that information affecting the aforementioned admission, discharge and transfer of patients be sent electronically to applicable providers, so that the medical team has a record of events associated with that patient. The hope is that this safe, electronic transmission of data ensures an accurate health picture among all providers, with all relevant parties notified accordingly and patients gaining access to these details as well.

Case Management and Discharge Resources  During the Coronavirus Pandemic

This goes hand in hand with the Final Rules governing health technology standards and providers. Together, these final rules reinforce the Trump administration’s attempt to improve patient access to their own health records (the MyHealthEData initiative), regardless of where services took place. The big takeaways from that update included a requirement that CMS-governed payers and healthcare organizations like Medicare Advantage and MCOs make patient health information available through APIs and that the information-blocking efforts of EHR vendors is restricted. The policies affecting Patient Access and Provider Directories also set a FHIR-based standard that all applicable Medicare participants are required to adhere to.

The delay of these rules means providers and the IT and infrastructure teams in support of those providers can delay preparation for those changes and instead focus on bolstering the clinical work that’s so critical during the pandemic. It’s important to understand, however, that these rules are being delayed, not thrown out altogether. You need to continue to plan for their implementation, even if you don’t do so right this moment.

But here’s where it gets really interesting: the standards outlined by these rules are the very things that can help you coordinate your response to the COVID-19 pandemic. The chief of HHS' Office of the National Coordinator for Health Information Technology even said as much in an interview given as part of HIMSS20 Digital. Electronic transmission of ADT data can ensure all healthcare providers know the details of a patient’s healthcare encounter and can respond accordingly.

Discharge provides a perfect example. The ability to view and send information about a patient’s condition quickly, via electronic means, is crucial when determining if a facility is capable of accepting a COVID patient. The ADT CoP rules boost these types of communication, streamlining the process and ensuring an adequate medical response.

At no point in history has it been more important for providers to coordinate their actions and share their knowledge. The ironic thing is the interoperability rules are being delayed at the very moment when their implementation could unite providers in a crisis like never before.

So while these rules are delayed, it’s important to continue progressing toward the secure storage and transmission of patient health data according to FHIR standards. Doing so will help everyone in the long run.New call-to-action

Hospitals Without Walls

For Medicare reimbursement purposes, there’s always been a strict divide between acute providers and post-acute care providers such as rehabilitation hospitals, psychiatric care facilities, nursing homes, etc.

Recognizing the need for increased capacity, both for incoming COVID-19 cases and the convalescence of recovering COVID patients, CMS has introduced “Hospitals Without Walls,” which aims to free up space by waiving rules that have long required delineation between acute and post-acute spaces.

As part of this initiative, CMS is allowing hospitals to receive reimbursement if they treat patients in post-acute spaces where acute care has traditionally not taken place. This will enable health systems to separate their non-COVID patients from their COVID patients, and it also ensures a patient isn’t forced to remain within the hospital longer than they have to.

This new system reinforces the importance of the acute/post-acute provider partner relationship like never before. With volume swinging wildly as outbreak clusters pop up around the country, hospitals need open lines of communication with their preferred provider network. They need to know who has beds, what types of patients those PACs are willing to take, and what new facilities are coming online in order to meet demand.

You can see how interoperability and electronic communication plays into this as well. As “Hospitals Without Walls” pushes hospitals to think outside the box (literally, in this case), the need for information sharing is greater than ever. So you have this interesting give and take where CMS is pulling back on enforcing one rule, interoperability, while supporting another initiative that directly benefits from the unenforced rule.

Read About How to Speed Up Discharge Communications

Workforce Virtual Kit

In April, CMS released a toolkit specifically focused on the workforce hurdles presented by the COVID-19 pandemic.

The idea behind this toolkit is to ensure that leaders in the healthcare space have the knowledge necessary to make informed decisions about their staffing needs during the pandemic. It includes things like best practices, information about workforce waivers, liability information, training resources, funding information and more.

Anyone in the acute or the post-acute space who is managing any of these issues should Bookmark the page, subscribe and revisit it often to make sure they’re following the advice outlined here. Because this is a CMS resource, it will be updated with the latest policies governing your facilities, and it therefore should be consulted regularly to make sure you understand rule changes affecting payments, flexibility, etc.

Never a Dull Moment

CMS’s willingness to push back and adjust certain rules likely caused a sigh of relief among many providers. With the unmatched stress of COVID-19, it makes sense that an additional regulatory burden is being delayed. In fact, we wouldn’t be surprised if some of these directives were pushed back further if we see a second wave of cases next fall or winter.

That said, things like interoperability are topics that aren’t going away anytime soon. They point to the future of care, and they’re critical to work toward in order to create secure infrastructure, steady Medicare reimbursement and an improved patient experience during the pandemic and long after.

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Meet the Author

Justine Olsen serves as Healthcare Strategy Analyst with CQuence Health Group. Prior to joining CQuence, Justine provided consulting services to medical practices and health systems participating in CMS’ Transforming Clinical Practice Initiative. Justine also has experience in administration of community-based behavioral health programs. Justine holds an MSc in Public Policy & Administration from the London School of Economics and Political Science, and a B.A. in Political Science from Creighton University. She has also received a Lean/Six Sigma BlackBelt - Healthcare professional certificate from Villanova University.