From Pain to Gain: Turning CMS-0057-F Mandates into Workflow Wins with BPM+

Wherefore CMS-0057-F?

In a two-part blog earlier this year (Part 1, Part 2) I discussed the role of orchestration between the various stakeholders engaged in patient care, as stipulated in rule CMS-0057-F from the Centers for Medicare and Medicaid Services (CMS).

What was the need for this rule and how can BPM+ Health modeling tools help to achieve compliance?

What was the need?

Many rules and regulations arise because of a real or perceived problem. Anyone involved in healthcare knows that it has many problems but seemingly few solutions.

Two of the biggest problems are (a) finding and accessing patient data in a secure and confidential manner and (b) properly identifying the patient. Hence the emphasis in CMS-0057-F on interoperability with FHIR and SMART on FHIR.

But there are many other problems. Some of these include:

• Often the patient has no idea about what is going on, especially behind the scenes.
• Delays or denials in preauthorization have raised concerns about patient safety and care quality.
• Multiple doctors may be engaged in a patient’s care, and they may need real time access to information.
• Referrals are a recurring problem, especially around miscommunication, resulting in a liability landmine.
• The frustrations of dealing with preauthorization is a contributor to clinician burnout.
• The entire preauthorization process is inefficient, manual, expensive and opaque.
• There is the perception by clinicians that some payers have abused the process, creating a system where they act as judge and jury.
• CMS (as well as everyone else) has limited insight into what is going on at any one time, making improvements difficult to achieve.

How can BPM+ Health modeling tools help?

As mentioned in the previous blog, there is a need to orchestrate multiple parties, and modeling tools can be very effective in achieving this.

One of the problems in healthcare is that too much of it is non-standardized. There are many reasons for this; however, this makes developing complex processes very difficult. BPM+ modeling encourages the use of standard approaches to solving problems. This is only a small step in the right direction, but it is better than relying on a legacy solution.

There are many opportunities for failures or exceptions to occur. Processes need to be able to adapt to these situations, and to escalate the response as needed. Handling these situations can be done efficiently in BPM+ models.

Finally, one of the biggest problems in healthcare is a lack of documentation. Not being able to know what happened in a given situation makes it difficult to provide a solution. Models maintain a trace of their execution, allowing audits of a specific case.

Conclusion

The financing of healthcare in the United States has become horribly complex. There are many pieces that all have to work together, but few do. Hopefully CMS-0057-F will bring improvements.

Compliance with CMS-0057 is anything but simple. Using the right tools can increase the chances of successfully achieving compliance. Otherwise, good luck.