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December 17, 2021

Open core systems are key to healthcare compliance — and beyond

With open core systems, health organizations can ensure both compliance and a frictionless, consumer-centric experience.

Some healthcare organizations probably sighed in relief when the Centers for Medicare and Medicaid Services (CMS) delayed enforcement of the payer-to-payer data exchange provision in its Interoperability and Patient Access rule. In contrast, our most forward-thinking healthcare clients understand that this and other, newer CMS regulations are bringing healthcare into the consumer-centric healthcare age.

These organizations want to comply with the spirit of these regulations so they can enable the frictionless healthcare experiences that consumers now expect. To do so, they’re leveraging the openness of their core administrative systems to enable the data flows, orchestration and analysis essential to new healthcare experiences.

The letter of the law

Here’s how we’re helping organizations respond to three major regulations:

  1. Interoperability. This rule will enable members of CMS-regulated health plans to securely access and share their electronic health information in digital form with any entity they choose. We’re helping clients create application programming interfaces (APIs) required by the rule.

    For example, we collaborated with Geisinger to build a comprehensive interoperability strategy, including creating a patient access API, a provider directory API and a portal for third-party developers using our TriZetto® Connected Interoperability Solution that draws data from our Facets and QNXT core platforms. The goal is to give members quick and easy access to their clinical and administrative data.

  2. Transparency in Coverage. This rule requires health plans to give members accurate cost estimates so they can assess what their healthcare decisions will cost and compare options. To comply, clients must generate machine-readable files from core solutions (Facets, QNXT and QicLink) that disclose in-network provider negotiated rates, historical out-of-network allowed amounts and drug pricing information. The agencies have since deferred enforcement of the need for a machine-readable file for drug pricing information pending future rulemaking.

    We’re helping clients prepare to deploy self-service cost estimate tools that personalize cost information according to a member’s plan benefits. One large client is preparing for this rule by using Facets’ Open Access real-time claims processing services and its Facets Accumulator Synchronization solution. The latter will give members an accurate picture of their remaining plan deductible amounts by synchronizing accumulated amounts between the client’s Facets core and its pharmacy benefits manager system.

  3. No Surprises Act & Surprise Billing Regulations. This rule is primarily designed to prevent surprising billing by out-of-network providers. One key requirement is that payers must provide information similar to an explanation of benefits (EOB) but to do so before the member receives the service. Our clients already using Facets Open Access solution have a library of APIs, as well as sets of business process automations, required to populate the advanced EOB.

How to capitalize on open core

On-demand access to health data, cost estimation tools and advanced EOBs can all become important components in new health experiences and services. To create these capabilities while complying with the rules quickly and cost-effectively, healthcare organizations need to capitalize on what open core platforms can offer, which includes:

  • The ability to access required data elements from the core. These data elements include contracts, capitation amounts, fee schedules, bundled procedure pricing and benefits plan design. Required member-specific data includes deductible and accumulated amounts, negotiated rates for plans, out-of-network allowed amounts, required pre-authorizations, claims and medical management.

    When this data can be retrieved directly from the core via exposed APIs, up-to-the-minute accuracy is ensured. Tapping an open core is especially potent when the core can stream event-driven data. One of our clients makes real-time claims status and prior authorizations available to providers and members using Facets Data Publishing to stream this data as it is generated.

    Contrast that approach with creating custom data file formats fed by core systems. These static formats must be redesigned as regulations change, slowing an organization’s ability to remain compliant. They also must be customized to feed data to other internal and external systems, and the system interfaces updated when regulations change.

    • Key action: Upgrade core systems to current versions. Vendors of core systems need to ensure their systems are compliant long before CMS enforces deadlines. Core data and processes should support the latest regulatory requirements. Vendors with open, standards-based systems generally have a streamlined path to exposing required data.

  • Fluid data flows among multiple systems and entities to support on-demand access. To create compliant machine-readable files with pricing information, organizations need data from the core system, as well as other internal systems, provider systems, clearinghouses and third-party administrators. When the core uses APIs and industry standards such as HL7 FHIR and USCDI, it’s easier to integrate the essential data from it with other systems in the payer landscape, such as member portals and apps, care management and quality systems, enrollment and submission processes, and print and fulfillment vendors. Closed core systems require multiple custom interfaces to connect to these systems, all of which come with maintenance and upgrade costs.

    • Key action: Evaluate how the requirement to integrate data from a wide range of systems creates new possibilities for business and operating models. These new mandates can serve as the basis for giving members health insights, unifying their health experiences across physical and digital channels, and removing friction points, such as by automating pre-authorizations using comprehensive health histories.

  • Enablement of new experiences even as regulations evolve. Interoperability, price transparency and surprise billing regulations likely will be fine-tuned after they take effect to address unanticipated consequences. Unresolved questions and potential issues shouldn’t be used as an excuse for delaying work toward compliance. Be assured that digital entrepreneurs and tech giants are using these regulations as blueprints for building new offerings and extending their reach among consumers.

    • Key action: Develop a compliance plan. Even organizations that only expect to comply with the letter of these regulations must be clear on how they will achieve that status. CMS provides an inventory of guidance on interoperability guidelines as a good starting point.

By leveraging the openness of their core systems, healthcare organizations can achieve regulatory compliance. By going beyond mere compliance, they can use those open cores to compete by building the capabilities their members wanted yesterday.

Surya Gummadi

Executive VP and President, Cognizant Americas

Surya Gummadi

Surya Gummadi is President of Cognizant Americas, responsible for the strategic direction and operational performance of Cognizant’s business in the US, Latin America and Canada. Additionally, he is responsible for the global large deals team.

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