Countdown to Compliance Part II: Answers to the Most Frequently Asked Questions About E-Notification Requirements Under CMS’s New Interoperability and Patient Access Rule

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 By Jay Desai

In my last column, I answered some of the most frequently asked questions regarding the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access Rule. The rule creates a new Condition of Participation (CoP) provision that requires hospitals, psychiatric hospitals, and Critical Access Hospitals to share electronic event notifications (e-notifications) with other providers across the continuum of care whenever patients have inpatient or emergency department care events. This compliance requirement goes into effect on May 1, 2021 and adds to the list of CoPs hospitals must fulfill to successfully maintain their CMS certification.  

The first set of questions center around how the CMS ruling defines “real-time”; whether existing HIEs can confer automatic compliance; and what types of providers need to receive e-notifications. In this second part, I will address some hypothetical situations that hospital CIOs and compliance chiefs may encounter, and attempt to clear up confusion about the application of the ruling to other providers and players in the healthcare value chain.

Would providers, such as SNFs, that receive e-notifications from hospitals also need to be responsible to send e-notifications to home health agencies and hospices?

This e-notification CoP only applies to hospitals, psychiatric hospitals, and Critical Access Hospitals. It does not include e-notification provisions or requirements for other types of providers. There are currently no CMS requirements in place that would require SNFs to send e-notifications to other post-acute providers or care settings.  

What about notifying the patient’s insurance carrier?

Under the minimum CoP requirements outlined in the final rule, hospitals have to send notifications only to the patient’s established primary care practitioner, practice group or entity; the practitioner, practice group, or entity identified by the patient as primarily providing his or her care, and applicable post-acute providers and suppliers. Insurance carriers are not included in this minimum set of recipients. However, CMS states in the final rule that the CoP requirements only represent a minimum floor and do not prohibit the sharing of information with additional parties for treatment, care coordination, or quality improvement activities as long as required data sharing agreements are in place and all state and federal laws and regulations are followed.

How would post-acutes or PCPs respond to a notification? Can they send a reply to the hospital system?

There is no prescribed way for post-acutes or PCPs to respond to e-notifications they receive from hospitals. CMS also does not require a “read receipt” from e-notification recipients. However, given the intent of the rule, the expectation is that recipients will use the information to support their care coordination efforts, improve communication across the care continuum, and thereby improve patient outcomes. CMS hopes to support providers through added access to important information about their patients so these goals can be realized.

Admission, Discharge and Transfer (ADT) data feeds can go down from time to time, what is the allowable recovery process and time that avoids penalties?

Any downtime should be minimized, but in cases where downtime does occur, it should be documented and resolved as quickly as possible. For audit purposes, it will be beneficial to document information about downtimes so that any e-notification lapses can be justified and explained. Hospitals or intermediaries should always address the root causes of any downtime to ensure that there are no systematic gaps in information sharing introduced and/or perpetuated.

What is the penalty for non-compliance with the new CoP requirement?

CoPs are the most significant and consequential regulatory lever that CMS has to authorize or terminate a hospital’s certification. CMS certification determines whether hospitals can receive Medicare and Medicaid payments, which often make up more than 50% of a hospital’s payer mix. To receive or maintain certification, hospitals must meet all CoPs, making compliance with CoP standards and conditions essential to hospital operations.

Will additional information be published by CMS that specifies the format or other details about the rule?

There will not be any foreseeable modification to the CMS Interoperability and Patient Access Final Rule, given that it has already been finalized and published in the Federal Register. However, the CMS Center for Clinical Standards and Quality will publish interpretive guidelines for the e-notification CoP that will give additional information and instructions to the survey teams as they assess hospital compliance. 

To learn more about the e-notifications CoP, visit www.adtnotifications.com.

Jay Desai is CEO & Co-Founder of PatientPing.

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