Rule CMS-0057-P and Your Healthcare Organization

Albert Einstein famously said that “information is not knowledge” – meaning we can have access to data but not always understand it. In healthcare, this can refer to the minutia – both on paper and in the cloud – that patients and providers consume, but don’t have the capacity to process. There’s just too much documentation.

In this light, the Centers for Medicare & Medicaid Services (CMS) is proposing new measures for electronic prior authorization processes. The efficiencies and transparencies encouraged with Rule CMS-0057-P are intended to reduce provider documentation burden and patient confusion to improve health outcomes. Information should, under this rule, be conveyed more simply and quickly, and be much easier to understand and apply.

If your facility operates without electronic health records (EHR) software – integrated with electronic prior authorization, your team might want to fast track EHR implementation. If adopted, Rule CMS-0057-P will go into effect in 2026.

What Will Rule CMS-0057-P Change?

CMS is working to solve common administrative problems related to prior authorization to expand access to treatment options. Currently, patients endure long waits for treatment, and sometimes don’t end up being treated at all.

Rule CMS-0057-P requires:

1. Regulated payers to include information about patients’ prior authorization decisions to help patients better understand the process and its impact on care
2. Impacted payers to build and maintain a Provider Access API (application programming interface) to share patient data with treating providers
3. Payers to exchange patient data when a patient changes health plans in order that patient data can follow them throughout their healthcare journey
4. Impacted payers to build and maintain a Fast Healthcare Interoperability Resources (FHIR) API that would automate the process for providers to determine whether prior authorization is even required
5. Some clinicians, eligible hospitals and critical access hospitals (CAHs) to request prior authorization using data from certified EHR technology (CEHRT)

What Will Rule CMS-0057-P Mean for Your Healthcare Organization?

By streamlining the prior authorization process electronically, CMS believes providers will experience a reduction in documentation burden. (Providers that have exclusively used an electronic prior authorization for medication requests have reduced their administrative workload by 2.5 hours each week.) This will free them to spend more time with patients, who will benefit from greater access to and understanding of this prior authorization process. In concert, time-savings and knowledge boosts like these should result in better patient health outcomes.

What Should Your Healthcare Organization Do to Prepare?

If your facility is not equipped with EHR software, it’s time to go digital.

And if your facility encompasses an operating room, enhancing your EHR with AORN Syntegrity® is also a great idea. AORN Syntegrity offers current procedural terminology (CPT) mappings that can help with prior authorization workflows. Sign up for a free consultation today.

Additionally, CMS is collecting comments on how Medicare might best support improvements to the exchange of medical documentation in order to better inform care and help providers treat patients. You can review Rule CMS-0057-P – and submit public comment (prior to March 13, 2023) – online.

Together, we can turn information into knowledge and put it to work for our patients!