FHIR offers potential to automate, expedite prior authorization

The emerging standard holds promise in helping payers and providers move patient information seamlessly to make care reimbursement decisions.

Proponents of Fast Health Interoperability Resources (FHIR) say the information exchange standard is a leading candidate to facilitate information exchange, particularly when it comes to efforts to remove the barriers that make prior authorization difficult.

In the midst of that effort is Tony Sheng, vice president of interoperability solutions for ZeOmega and member of HL7’s Da Vinci Project. At a recent Da Vinci Project community web-based meeting, Sheng and fellow Da Vinci member, Change Healthcare’s Craig Knier, demonstrated the use of FHIR and application programming interfaces (APIs) to enable real-time prior authorization between providers and payers.

The effort to incorporate FHIR to solve vexing prior auth challenges is significant because relatively few such communications between providers and payers are accomplished in even a partially automated way. Most of these intricate transactions are time-consuming, labor-intensive and put many patients at risk while they are waiting for their care to be approved, trade groups say.


Sheng said the use of FHIR and APIs to speed the prior authorization process is exciting and holds promise for things to come. But it’s not a silver bullet, in the long run, because “FHIR is just a set of standards,” he says. Providers still have to get all documentation necessary when it comes to compiling all the needed clinical evidence to get an authorization passed. 

“Technology is great, but it needs to be in the right workflow,” Sheng says. “Someone can say they know how to use FHIR and create all these APIs, but do they really understand how to use this in a workflow?” Because in the end, “payers aren’t interested in FHIR, necessarily. They want better communication.”

After workflow is addressed, the next big question is trust. Payers and providers need trust in third-party interoperability companies--that the data will be secure when they are handling it. Sheng says the remedy for that is security certification. “So far, no one is really carrying the torch on this,” he says. The Office of the National Coordinator for Health information Technology’s FHIR at Scale Taskforce (FAST) has recommended security certification, but the recommendations are “somewhat buried.”

In addition to security certification, interoperability platforms need to certify that they can in fact exchange the data by having a third-party test. “Two parties might agree on a standard, but it’s not always plug and play,” Sheng says. Standard criteria testing is a good way to ensure data exchange will be possible under FHIR.  

Tony Sheng

ZeOmega has led by example, announcing in October that it had successfully passed all three comprehensive data security and interoperability testing programs, known as the Security and Interoperability Trifecta. “By passing all three testing programs, ZeOmega and its interoperability platform, HealthUnity, are certified as meeting and exceeding the highest industry-defined requirements for data exchange and information security,” ZeOmega said.

Sheng says more companies need to begin using FHIR for prior authorization to work. “You can’t test this process with yourself. It’s all about ecosystem," he says. “When you’re talking about prior authorization transformation, it’s not just about us wanting to promote us doing it. We want to lead by example, so others can also follow.”

The good news is, Sheng says he’s starting to see a tipping point on the adoption of FHIR. “We’re seeing so much momentum building up in the past two to three years. Healthcare is all about adoption.” Sheng attributes much of this advance to the Da Vinci Project. “What Da Vinci has done has given use of FHIR so much more exposure and value.” Return on investment is there for the taking, Sheng says, and integration is becoming that much more accessible.

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