By: Melanie Combs-Dyer, Director of Innovation, Mettle Solutions
The United States has one of the world’s most complex healthcare systems, with different organizations providing different types of care across geographic and clinical lines as well as with hundreds of separate payer organizations often with differing documentation requirements to justify coverage/payment. Providers can often feel overwhelmed by the differing and hard to access documentation requirements of the various health plans.
DRLS Language in CMS Interoperability NPRM Preamble (March 2019)
In 2017, the Centers for Medicare & Medicaid Services (CMS), Blue Cross Blue Shield Association (BCBSA) and several other payers began working with Da Vinci project, a private-sector initiative led by Health Level 7 (HL7), to promote interoperability between payers and providers (and their EHRs and Practice Management Systems). For one of the use cases under this project – called “Coverage Requirements and Documentation Rules Discovery” – the Da Vinci project developed a draft Fast Healthcare Interoperability Resources (FHIR) standard during the summer and fall of 2018.
In June 2018, in support of the Da Vinci project, the CMS Medicare FFS program began:
developing a prototype Documentation Requirement Lookup Service (DRLS) for the Medicare FFS program;
populating it with the list of items/services for which prior authorization is required by the Medicare FFS program; and
populating it with the documentation rules for oxygen and Continuous Positive Airway Pressure (CPAP) devices.
More information about the FFS Medicare program’s efforts to support these Da Vinci use cases are available at go.cms.gov/MedicareRequirementsLookup.
In February of 2019, CMS released an Interoperability Notice of Proposed Rulemaking (NPRM). In the NPRM, CMS encouraged all payers, including but not limited to MA organizations, Medicaid managed care plans and CHIP managed care entities, and QHP issuers in FFEs to follow CMS’s example and align with the Da Vinci Project to:
develop a similar lookup service;
populate it with their list of items/services for which prior authorization is required; and
populate it with the documentation rules for at least oxygen and CPAP.
CMS articulated in the NPRM that by taking these steps, health plans could join CMS in helping to build an ecosystem that will allow providers to connect their EHRs or practice management systems work flows with up-to-date information on which items and services require prior authorization and what the documentation requirements are for various items and services under that patient’s current payer
Benefits of Encouraging Payers Uniformity in Required Documentation Elements
There are a number of benefits that could be recognized if required documentation elements were more uniform across payers. If payers had more commonality in their required data elements, payers might create reduced provider burden by:
more quickly developing DRLS mechanisms,
speeding up the length of time it takes to make a prior authorization, pre-claim review, and prepayment/postpayment determinations through more automated review mechanisms, and
more efficiently seeing where new USCDI and/or USCORE data elements are needed
Medicare FFS Data Element Library and VSAC
When evaluating the documentation elements required by payers for coverage of certain post-acute care facilities -- such as Home Health Agency (HHA) services, Inpatient Rehabilitation Facility (IRF) services, Skilled Nursing Facilities (SNF) services, etc. – payers should consider adopting the data elements required in the Medicare FFS “assessment tools.” These tools are often referred to as:
OASIS (for HHA services),
MDS (for SNF services) and
IRF-PAE (for IRF services)
The data elements used in the OASIS, MDS, IRF-PAE and other assessment tools are listed in the Data Element Library (DEL).
The VSAC is the …
An early public discussion on this topic occurred during the summer of 2019 when Don Rucker, MD, the Director of the Office of the National Coordinator (ONC) for Health Information Technology was hosting a Provider Burden/Prior Authorization meeting. A member of the audience asked why health plans could not agree on a common set of rules under which to consider a given item/service covered and medically necessary. Dr. Rucker responded that although it would be inappropriate for health plans to set a single set of national rules, it would make sense for health plans to agree on common sets of required documentation elements.
At the May 2020 Virtual FHIR Connect-a-thon, a number of the participants in the prior authorization track (including Beth Connor of CMS/Medicare FFS, Nick Radov of United, and Jeff Brown of CIGNA) indicated that:
If payers could agree on common required documentation elements, it would likely reduce provider burden,
It would be difficult and time-consuming to achieve such agreement without an organized process to ensure that meetings are set up, decisions are recorded, research is conducted, agendas are set up, open issues are documented, etc.
Participants at the May 22, Da Vinci Prior Authorization Support (PAS) Workgroup meeting, continued the discussion. Some participants felt that an HL7 workgroup or a Da Vinci workgroup would be the ideal framework in which to help payers work towards more uniform required documentation elements. There was also discussion about who should participate in the effort to develop more uniform documentation elements. The conclusion was that while the primary participants would be payers, it would also be advantageous to have participation from providers and other interested parties.
B. Proposed Membership and Meeting Cadence
The Payer Uniformity Team should:
Seek payer volunteers who wish to participate in project to attempt to reach consensus on a uniform set of documentation elements that providers would need to document in a medical record to support coverage and medical necessity of given item/service,
Seek one or more provider volunteers,
Welcome all other interested parties who wish to participate
2. Meeting Frequency.
The Payer Uniformity Team should meet (virtually) for 1 hour per week.
One or more team members should provider a verbal report to an HL7 or Da Vinci workgroup once per month.
C. Objectives of the Project
As a result of this project, the following outcomes will be achieved:
Encourage more structured medical records (by moving more required documentation elements into USCDI and US CORE codesets)
Reduce provider burden by:
eliminating unnecessary documentation requirements
reaching consensus, where possible, on necessary documentation elements to support the coverage and medical necessity of an item or service
allowing instantaneous prior authorizations, pre-claim reviews, and provider self-checking
allowing faster prepayment review and postpayment review
Shorten each participating payer’s timeline to populate their DRLS,
D. Project Activities
1. Establish the Payer Uniformity Team.
As of June 10, the following individuals have volunteered:
2. Choose the first topic (item/service)
The Payer Uniformity Team will choose the first topic. Ideally, it would be a topic for which:
Some or all of the payers require medical record documentation to support prior authorization, coverage/medical necessity
Medicare FFS has listed its required data elements on the CMS website
One additional criteria could be: The Medicare FFS program has an assessment tool for the item/service
3. Decide where Uniform Documentation Elements should be written. For example,
Home Health Required Documentation Elements could be written in the eLTSS FHIR profile (see http://hl7.org/FHIR/US/eltss/)
Each set of Uniform Required Documentation Elements could be written in a Supplemental Guide for DTR.
4. Identify a “lead” participant for the first topic
The lead will volunteer to, each week:
Set an agenda for the weekly subgroup call
Facilitate the discussion in the subgroup call
Document the decisions made at the subgroup call
Set up any off-line calls that are needed between weekly subgroup calls
Provide a verbal report at a monthly HL7 or Da Vinci workgroup on the progress made by the Payer Uniformity Team that month.
5. Identify the appropriate HL7 or Da Vinci workgroup to sponsor the team.
HL7 Patient Care Workgroup
HL7 PI Workgroup
HL7 Financial Management Workgroup
Da Vinci Documentation Templates and Rules Workgroup
6. Develop a Project Scope Statement (PSS).
The team develops a PSS following the HL7 suggested outline.
7. Each payer clears any changes to their current requirements internally within their own organization
8. For each topic, the payers bring their required documentation elements to the team. The team compares all to identify commonalities and differences. Payers with outlier elements are asked to explain why they require a given element. Providers and guideline companies are encouraged to highlight potentially outdated requirements and/or missing requirements.
It may be helpful for one or more of the volunteers to translate the documentation requirements into if/then flowcharts
9. Each payer begins the clearance process for any changes they want to make to their required documentation elements.
10 Each payer populates its DRLS with its documentation elements for the first topic (once it emerges from that payer’s clearance process)
11. Conduct a DRLS Proof of Concept demo to ensure that DRLS cards are rendering similarly
12. Analyze each Required Documentation Element to see if a new USCDI, US CORE, LOINC and/or review result reason code set exists for that element
13. Submit a request:
a. To ONC for new USCDI code sets;
b. To HL7 for new US CORE data elements
c. To ____ for LOINC codes
d. To CMS/PCG from Review Result codes