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8 Ways CMS Interoperability Rule can affect Billing in Healthcare

The Interoperability Rule put forward by the Centers for Medicare and Medicaid Services has been implemented from July 1, 2021, after a delay of six months to give the stakeholders more time to comply with the changes. Any non-compliance with the rules can get the providers as well as payers penalized for their actions. But with the fast changing medical rules, how are the systems going to evolve their billing in healthcare? What are the things they should look out for?

Providers need to be on their toes with their systems because this is just the beginning of the massive changes that are going to get implemented by 2024. Now with the CMS Interoperability Rule in place, let’s look at the ways billing in healthcare is going to change.

1.Security Measures:

  • The goal of the CMS Interoperability Rule is to make healthcare information more accessible and available to the patients.
  • This is the reason CMS is pushing towards more EHR integration for the easy transfer of files within and between the organizations.
  • To ensure proper billing in healthcareis in action, independent providers and provider organizations should take note of their data security measures.
  • Most healthcare organizations are strongly implementing user-friendly application programming interfaces (API).

2.HIPAA Compliance:

  • Without proper HIPAA compliance, both maintaining patient records and billing in healthcare can run into trouble.
  • HIPAA is the gold standard of data security. Now with interoperability running its course, the quality maintenance has gone one step further.
  • For trusted rule implementation through secure APIs, the CMS has published the Health Level 7Fast Healthcare Interoperability ResourcesRelease 4.0.1.
  • In addition to the rules of HIPAA, CMS feels that the healthcare organizations should work diligently to put the new standards in place.

3.ADT Information:

  • According to the CMS, the providers or their organizations must be capable of securely maintaining the patient records with respect to Admission, Discharge, Transfer (ADT).
  • This means that healthcare institutions must be ready to remove or update any redundant systems in place at the earliest.
  • The CMS has also clearly stated that this is the first step towards maintaining compliance with its rule.
  • Without the required steps from the organization, the services renderedby these providers or organizations will be noted with a reduced rate.

4.Transfer of Data:

  • Seamless transfer of patient health information is one of the key aims of this new rule of the CMS.
  • Therefore they want to ensure that the healthcare organizations have enough resources to generate and transfer the data to another healthcare provider or the patient.
  • CMS wants the healthcare organizations to use the secure ADT messenger to transfer the required data.
  • For that to happen, the organizations must ensure that their EHR systems are well-prepared for such a function.
  • Without upgraded EHR systems in place, providers are likely to miss out on proper reimbursements from the payers.

5.Updating Contact Information:

  • The providers are required to update their contact information on the National Plan and Provider Enumeration System under the new rule.
  • According to the CMS, the updated digital contact information is going to support the providers and the healthcare organizations in the rules to come.
  • In the case that the provider is aware of the Fast Healthcare Interoperability Resources end point information, it is advisable to put in the details as well.
  • Any non-compliance with this rule might get the identified providers reported publicly. To ensure that the billing in healthcare continues seamlessly, make sure that you keep the information updated.

6.Informed Patient, Better Outcomes:

  • Payers are undergoing several changes on their web portals as well as in print to boost the patient education about their healthcare plans.
  • This can help the providers in billing in healthcare since they will be highly benefitted by a more informed patient.
  • With incorrect and inaccurate data on the patient forms, the subsequent procedure of the bill preparation and collections become unnecessarily complicated.
  • The patient education resources will boost the provider-patient transparency, leading to better financial outcomes for the organization and better clinical outcomes for the patient.

7.Payer-Provider Integration:

  • A great benefit with this interoperability rule will come in the form of payer-provider integration and an increased transparency in operations.
  • Medical billing in healthcare has suffered a lot because of lesser coordination between the payer networks and the providers.
  • Sufficient data exchange will lead to greater clarity in patient eligibility verification, enrollment details and credentialing requirements.
  • It will not only help the providers to stay updated on the payer’s latest modifications but also to give the patients a more holistic form of care.

8.Insurance Eligibility:

  • Patients often coming through for medical procedures have multiple insurance payers.
  • This information is crucial for the billing team since it helps them to prepare the claim accurately and put the correct charges in the separate accounts.
  • The interoperability rule not only applies to the payer-provider relationships, but also boosts the transparency between different payer networks.
  • Experts feel that moving forward, improved payer-payer relation will help to substantiate the information regarding the patient’s bills.
  • This will in turn help the provider organizations to bill the patients with greater care, while also reducing the billing time.

Closing Thoughts

The CMS Interoperability Rule comes as a fresh change in the healthcare industry, with the aim to make healthcare more accessible for all the players of the medical field. Coupled with advanced legislations like the No Surprises Act, the authoritative bodies are moving towards a more concise medical ecosystem. However, the tight deadlines have led the providers to be confused, leaving them little time with patients. If you are suffering from a similar issue, then you can get in touch with the leading revenue cycle management companies to help you stay on top of bills.

We hope this blog helped you understand how the CMS Interoperability Rule can affect billing in healthcare. For any queries, write them below and we will get back to you. For more updates, subscribe to our blog and keep an eye out on our social media handles.


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