August 5, 2020

Compliance is About Customers: Make a Lasting Impact with CMS Interoperability Improvements

Jim Garrity

It's time to think beyond compliance, focus on your customers, and ultimately differentiate yourself from the competition. How? We'll show you.

What’s Good for Customers is Good for Business

Let’s face it: who doesn’t want greater, easier access to their health information? While it’s easier said than done to make that’s happening, and it’s happening very soon.

The Center for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) released policies that require health insurers to make patient information, provider directory information, and pharmacy information more available. That means data is easier to move between insurance companies (payers), medical professionals (providers), and the customer (patient). The end result? You and I will have better access to our health information. Eventually.

CMS’ Required Changes & Deadlines

Increasing access means updating the core systems and processes within organizations, both technical and structural. CMS has put together a detailed list of each area and application where they’ll be measuring compliance. Most fall under these buckets:

  • Technical platforms and tools: applications, identity protocol, and content.
  • Claims, clinical and coverage data.
  • Plan coverage and formulas.
  • Provider directories: helping customers find doctors/specialists near them.
  • Patient privacy and security.

There are many articles and resources available documenting the requirements of the CMS and ONC interoperability rules. IMPAQ has a helpful timeline with the key milestone dates. Complying with the CMS and ONC rules within this timeline is challenging in normal times. COVID-19 further exacerbates the pains felt by payers and providers as everyone is stressed to keep their patients and customers safe.

Unfortunately, the abundance of content available about the rules itself has created a lack of emphasis on the “what” and “how” for payers and providers to be ready.

We’re aiming to change that with a reframing of the problem, starting with the “why.”

Below, we’re focusing on the payer scenario, and in future posts, we’ll focus on the provider. Keep reading to learn how we’re advising payers to approach these new regulations—how they can think beyond compliance, focus on their customers, and ultimately differentiate themselves from the competition.

CMS Interoperability Timeline
IMPAQ's CMS Rule implementation timeline

The Why: Avoiding Risk AND Improving Customer Experience

You, the payer, must comply with this new regulation, which at its core helps advance the triple aim: better care, improved health, lower cost. Inaction will put your business at risk for punitive fines, market access restrictions, or becoming blocked from providing coverage to consumers.

This isn’t just a list of to-dos, it’s a massive opportunity. This is the biggest chance for leaders to double down on their customer’s experience – you are dedicating budgets, teams, and focus to achieve compliance. You can do it the best way with your customers’ experience in mind.

The flipside of the horrific health and economic impact of COVID-19 is the human ingenuity and innovation we’re seeing in the healthcare industry, which has, overnight, switched to digital technologies to treat and engage with patients. We can look at these CMS and ONC rules in a similar way – how might we innovate for our customers with this compliance mandate?

Consider this cause and effect:

  1. You enable customers through thoughtful, guided options, you empower them to make better care choices, and connect them to the best in-network doctors.
  2. The best doctors are treating them, the patient sees better outcomes.
  3. Improved NCQA scores help all network stakeholders; consumers, health plans, and physicians with benefits such as improving network integrity, trusted decision-making referral patterns, and leakage control.
  4. The referral network gets stronger.
  5. Happy customers will stick with you and the doctors in your network because being a member is easy, data is accurate, and care is consistent and high quality.
  6. Simple self-service options across channels empowers customer choices which leads to a network of better providers.
  7. The cycle feeds itself.

Meanwhile, integrated portals and self-service tools will lead to information capture that will power marketing activities. These strengthen the continuous improvement cycle above.

Breaking Down the What and How: Technology & Service Delivery

From a tactical perspective, payers must deliver two types of APIs and provide current and former customers easy-to-understand, non-technical information about how to access their health data across all channels.

Part I: Technology Delivery

Technically speaking, you will need to:

  • Meet patient access requirements: claim, encounter & clinical data from payers will be accessible via FHIR APIs. Government programs (including Medicare Advantage, Medicaid managed care, and ACA Exchange plans) are required to make available certain claims and clinical data elements to members using a secure, standards-based API.
  • Meet provider data and pharmacy requirements: Provider directory & formulary directories will be accessible via FHIR APIs. Government programs are required to make provider director information available via an API. In addition, Part D plans must make formularies available via an API.

Part II: Service Delivery

In tandem with technological updates, you need to execute:

  • Communication planning to customers.
  • Providing support for employees before, during, and after the change.
  • Training each business area prior to rolling out the changes.
  • Supporting exchange via digital channels (web, portals, voice, etc.).
  • Defining data components and ensuring that metadata is consumable.
  • Partnering with the technology organization to ensure clinical and business requirements are clear and aligned to delivery.

Part III: Differentiate Through the Customer Perspective

Think Like a Customer

Identify and emphasize the highest value customer moments that matter to prioritize path to compliance. The customer seeks ease of use and continuity of care. A portal powered by modern data exchange mechanisms enables intuitive, logical, and effective consumer engagement to get activity completed.

Act Like a Customer

Focus on “jobs to be done” and improve ease of use and accessibility considerations for age bracket demographic. Consider the UI/UX on the portal and the features that allow for engaging with you however the customer prefers.

Operate Like a Customer

Data privacy and personalized experiences work hand in hand to create an easy omnichannel interaction model that seamlessly updates all modalities & empowers-informs consumers in their decision making with the likelihood of reduced utilization of higher dollar channel “customer contact center”

Live Like a Customer (Support)

Limit sev1, sev2 defects by way of agile risk mitigation and realistic E2E testing along the way. The mechanisms for continuous improvement will be in place to ensure compliance and high level of service ongoing.

This customer-first approach is how payers will differentiate from the competition. The CMS and ONC requirements are onerous for sure, but they are also an opportunity to rethink how you engage with your customers. COVID-19 has taught us that we are beyond resilient; when change is immediately thrust upon us, we innovate new ways to deliver for our customers. Thinking, acting, operating, and living like your customer will further accelerate your digital journey, and if done smartly, elevate you from the competition.

SingleStone's timeline to CMS interoperability

Think Bigger for the Better

This is a lot, for any company, of any size. Focusing on one compliance at a time or the bare minimum necessary to meet compliance requirements will not provide long-term benefit. You need to think bigger. Putting your customer at the center and building out improvements will drive:

  • Higher Customer Satisfaction / NPS (preserve service levels)
  • Higher average NCQA score in network
  • Higher retention rates
  • Reduced network leakage
  • More personalized marketing and sales activities.
  • Limited enterprise disruption.
  • Modernization and business agility benefits to Credentialing, Network Design & Network Management
  • Increased product speed to market

You Can Do This, We Can Help

There is a lot of work to be done, but it's not insurmountable. At SingleStone, we focus on an agile approach to lofty goals. We help insurance payers break down those lofty goals with objective evaluations – looking at the components of service delivery models related to the design objectives of interoperability.

We don’t end at compliance, we take an empathetic, thoughtful approach to eliminate internal frictions to delight the end customer. As a result, our insurance partners receive:

  • A future state, high-level service model design with a plan to mitigate risks and ensure service model operational readiness.
  • A clear understanding of the key risks to each service model category.
  • Alignment among IT, Business, and Clinical leaders on the approach and plan for operations.

Are you ready to be compliant and separate your organization from the competition? Let’s talk.


Jim Garrity

Account Director
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