Federal RFI and potential law have implications for FHIR
An RFI on the No Surprises Act seeks more guidance on a use case, while House-passed law could provide more impetus to automate prior authorization.
Two recent federal policy developments are focusing attention on boosting access to healthcare information and improving administrative processes, including prior authorization and patient-facing communication.
The two initiatives provide broader opportunities for the use of the Fast Healthcare Interoperability Resources (FHIR) standard, said those involved with HL7 and its Da Vinci Project, an accelerator that’s been working to use FHIR to support information exchange initiatives aiding transactions between providers and payers.
In one development, federal departments of Labor, Treasury and Health and Human Services released a request for information (RFI) focused on the advanced explanation of benefits and good faith estimates for covered individuals. These are requirements of the No Surprises Act – part of the Consolidated Appropriations Act of 2021. Aspects of the No Surprises Act present significant challenges for healthcare organizations to comply with requirements for getting accurate estimates of medical expenses to consumers in advance of treatment.
"The Patient Cost Transparency workgroup continues to revise and update draft standard versions based on public comments received through the ballot process.” Comments on the RFI are due by November 15.
This RFI seeks information and recommendations on transferring data from providers and facilities to plans, issuers, and carriers; other policy approaches; and the economic impact of implementing these requirements.
The request specifically calls out the potential for using FHIR, APIs and the efforts from the Da Vinci Patient Cost Transparency (PCT) use case. It notes that Da Vinci “launched a Patient Cost Transparency project dedicated to developing an IG that could be used to exchange AEOB and GFE information,” the RFI notes. The current version of the standard for trial use “is useable by industry today, and the Patient Cost Transparency workgroup continues to revise and update draft standard versions based on public comments received through the ballot process.” Comments on the RFI are due by November 15.
Separately, on September 14, the House of Representatives passed HR 3173, Improving Seniors’ Timely Access to Care Act of 2021. The bill now moves to the Senate for further consideration.
The intent of this legislation is to accelerate the ability of senior citizens to receive quality care under Medicare Advantage by modernizing the ways in which Medicare Advantage plans and healthcare providers use prior authorization.
Prior authorization – which is intended to reduce improper payments and unnecessary care – has been the focus of much attention because of delays the process causes as providers and payers work out whether medical treatments will be covered.
The Da Vinci community has been prioritizing work on three use cases that aim to automate prior authorization procedures – these are Coverage Requirements Discovery (CRD), Documentation Templates and Payer Rules (DTR) and Prior Authorization Support (PAS). Those leading the Da Vinci efforts say these use cases align with the spirit of this law.