Industry Watch Alert
Key Takeaways
- HHS announced a final rule to provide real-time prescription drug price transparency and streamline electronic prior authorization via certified health IT.
- Providers using certified systems will be able to see patient-specific drug coverage, out-of-pocket costs, and prior authorization requirements at the point of care.
- The policy aims to reduce administrative burden, improve interoperability, and support more cost-effective prescribing decisions.
Impact
- For payers: Increases expectations for interoperability with certified health IT and transparency of formulary, benefit, and prior authorization data; may reduce call volume and manual reviews over time.
- For providers: Enables on-the-spot visibility into coverage and patient cost-sharing, supporting informed prescribing and fewer pharmacy callbacks; electronic prior authorization can shorten decision timelines.
- For value-based care: Facilitates lower-cost therapeutic selection and adherence by displaying patient-specific out-of-pocket costs and alternatives during clinical encounters.
- For revenue cycle/compliance: Better documentation and standardized transactions may reduce denials and support compliance with interoperability and transparency requirements.
Summary
HHS issued a final rule intended to give clinicians and patients real-time access to prescription drug price and coverage information through certified health IT. The policy supports electronic prior authorization and requires that certified systems enable prescribers to compare drug options consistent with a patient’s insurance coverage, view out-of-pocket cost information, and understand prior authorization requirements during the clinical workflow. The rule complements CMS policies on prior authorization and interoperability and aims to ease administrative burden, improve care timeliness, and lower costs by promoting price transparency at the point of prescribing.
Sources
- U.S. Department of Health and Human Services (HHS)
Americans to Gain New Access to Real-Time Prescription Price Information
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FAQ
Q1: What is changing for clinicians at the point of care through HTI-4?
Certified health IT must support tools that surface patient-specific drug coverage, out-of-pocket costs, and prior authorization requirements in real time to inform prescribing decisions.
Q2: How does HTI-4 affect payers?
Payers will need to support interoperable data exchange so certified health IT can retrieve formulary, benefit, and prior authorization information, improving transparency and reducing manual processes.
Q3: Will HTI-4 reduce prior authorization delays?
The rule is designed to accelerate electronic prior authorization, which can shorten review times and increase predictability for providers and patients.
Q4: How does HTI-4 support value-based care?
By enabling visibility into patient cost-sharing and lower-cost alternatives, the rule supports cost-effective prescribing and adherence, key elements of value-based models.
Q5: What should organizations do now regarding HTI-4?
Assess certified health IT capabilities, align payer-provider data exchange for formulary/benefit and prior authorization, update prescribing workflows, and prepare staff training to leverage real-time transparency tools.
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