Solutions to improve the prior authorization process and promote interoperability “must take the different needs of dental practices and medical practices into account,” according to the American Dental Association and American Academy of Pediatric Dentistry’s response to a proposed rule from the Centers for Medicare & Medicaid Services.
In comments submitted March 13 , ADA President George R. Shepley, D.D.S., and AAPD President Amr M. Moursi, D.D.S., Ph.D., commended the agency for efforts to streamline, clarify and reduce the burdens of the prior authorization process for patients and providers. They also thanked the agency for continuing to promote interoperability to facilitate the exchange of information between providers, patients and payers, noting that the proposed rule would be more effective for dental data exchange if CMS focuses on “educating, engaging and incentivizing” business partners to facilitate the move toward adoption of the standards discussed in the rule.
“Administrative efficiency can only be achieved if we have robust standards which are inclusive of specialties and small practices, and if all business partners use these standards to communicate information,” Drs. Shepley and Moursi wrote.
The AAPD-ADA joint comments focused on these six areas:
Exclusion of stand-alone dental plans
In the rule, CMS proposed excluding stand-alone dental plans offered as qualified health plans on federally facilitated exchanges. The ADA and AAPD urged CMS to not exclude stand-alone dental plans from this proposed rule because it is important that patients who are enrolled in these plans and the providers who working with them benefit from the improvements to prior authorization and increased interoperability. The groups encouraged CMS to provide technical assistance, financial incentives and time-limited safe harbor periods to enable the plans to meet the requirements of the final rule to prevent stand-alone dental plan attrition.
Claims data related to supplemental benefits
ADA and AAPD are asking CMS to recognize that the Patient Access Application Program Interface in its current version may not be able to represent all the essential benefit information for dental. They noted that the advancement of standards versions and the management of multiple versions “is a critical issue and is not sufficiently addressed” in the proposed rule. They also shared that they are actively working to modernize the data elements exchanged for eligibility, benefits and claims through the ADA’s Standards Committee on Dental Informatics, an ANSI-accredited standards development organization.
Patient Access Application Program Interface: United States Core Data for Interoperability Data
The ADA and AAPD said they support Office of the National Coordinator for Health Information Technology certification for dental vendors but noted most dental practices use electronic dental records and practice management systems that are unlikely to be ONC certified. This means that connecting changes in standards to the ONC Certification Program would not benefit dental providers, nor remove barriers to the exchange of dental clinical or administrative data. Both ADA and AAPD said they recognize that all stakeholders need time to plan, prepare and implement and asked CMS to move to at least United States Core Data for Interoperability version 2, which would encourage the industry to ensure that the data elements and classes made available through the Patient Access Application Program Interface are the most appropriate for information exchange. They would also like CMS to ensure that users of United States Core Data for Interoperability version 2 understand that CDT is optional only for systems that do not handle any dental data. It is the ADA’s and AAPD’s assertion that CDT is the only appropriate vocabulary standard for dental procedures and should be present to accurately represent dental clinical procedures in all health information technology.
Expanding HL7 Fast Healthcare Interoperability Resources Application Program Interfaces to include dental
The ADA and AAPD said they applaud CMS efforts to promote the adoption of Fast Healthcare Interoperability Resources-based APIs and noted they have worked closely with Health Level 7 to develop dual Clinical Document Architecture and Fast Healthcare Interoperability Resources implementation guides. They said both organizations hope that “the effort to improve and advance a HL7 Fast Healthcare Interoperability Resources Application Program Interfaces for prior authorization will include opportunities to promote interoperable solutions to a broader group of providers and healthcare specialties such as dental.”
“Gold carding” programs for prior authorization
The ADA and AAPD said they both support gold carding programs for prior authorization. They said that CMS and third-party payers should recognize the efforts of dentists who have a track record of complying with prior authorization requirements to ensure timely access to care for patients and to reduce administrative burdens. They noted that many dentists are small business owners and only have a limited number of staff members so gold carding could also help improve their efficiency. They recommended that the measure used in gold carding match the one used in the Medicare Fee-for-Service Review Choice Demonstration for Home Health Services: a review affirmation rate or claim approval rate of 90% or greater over six months.
Recommended standards to support Application Program Interfaces
The ADA and AAPD said they have several concerns about the recommended implementation guides for the Patient Access, Provider Access, Provider Directory, Payer-to-Payer, and Prior Authorization Requirements, Documentation, and Decision Application Program Interfaces. They said they believe these implementation guides “may be able to present some dental data but to our knowledge they have not yet undergone testing and review for suitability for dental needs.” They encouraged CMS to provide technical support and incentives for the dental industry in piloting and validating the standards named in this rule. They added that both ADA and AAPD are willing to help facilitate such initiatives.
Read the comments in full here .
Follow all the ADA’s advocacy efforts at ADA.org/advocacy .