Dive Brief:
- The CMS has finalized first-of-their-kind standards for providers to share claims documentation electronically in an attempt to phase out the use of faxes and physical mail, but stopped short of creating standards for the exchange of prior authorization documentation following pushback from the sector.
- The CMS’ final rule published Friday creates new electronic standards for sending information requested by insurers to support claims, such as medical records or lab results, compliant with federal privacy laws.
- The regulation also sets requirements for electronic signatures on the transactions to ensure exchanges are secure and authenticated. Payers and providers have until May 2028 to switch over to the new standards for sending electronic claims attachments.
Dive Insight:
Providers have long used outdated tools like faxes and direct mail to send documentation attachments requested by insurers to support their claims — hiking up costs and delaying care for patients, the CMS said.
Adopting electronic claims attachment standards should save the healthcare sector almost $782 million each year, allowing clinicians to spend less time on administrative tasks and focus on direct patient care, according to the agency.
“The 1980s called, and they want their fax machines back,” CMS Administrator Dr. Mehmet Oz said in a statement Friday. “The futuristic medical breakthroughs we’ve achieved, like augmented reality glasses that give surgeons X-ray vision, shouldn’t have to coexist with administrative systems that often lag decades behind.”
The final rule solidifies X12 data exchange standards for sharing administrative transaction data and HL7 standards for sharing clinical data, with the hope that standardizing data sharing will make it easier for healthcare organizations to send data electronically as opposed to through physical means.
However, the CMS did not finalize electronic transfer standards for prior authorizations that were included in the rule’s draft version in 2022.
Providers and payers had argued those stipulations would have set different data exchange standards for prior authorization than other federal government rules. The change also would have conflicted with an existing X12 standard for prior authorization, creating new complexities for the sector, commenters on the proposed rule said.
The CMS will continue evaluating other standards for prior authorization attachment standards, regulators said in a fact sheet on the rule.
The new standards will apply to all healthcare entities covered by the Health Insurance Portability and Accountability Act, or HIPAA, privacy law, including health plans, claims clearinghouses and providers.
The final rule comes as the CMS continues to prioritize streamlining the electronic exchange of health data, a long-term challenge for an industry often reliant on old technology.
Last year, the agency launched its Health Technology Ecosystem, a project that uses partnerships with technology and healthcare firms to speed data sharing and promote the use of digital health tools and artificial intelligence.
