HL7 initiative begins work on payer cost transparency

A workgroup in the standards organization aims to produce a standard for better communicate the cost of care.

An accelerator program within HL7 is working toward developing a standardized approach to address one of the great unknowns in healthcare – what’s this medical procedure going to cost?

Many variables go into that determination, and reaching a trustworthy estimate depends on quick and effective communication of information between payers and providers. The new initiative under the auspices of the Da Vinci Project aims to use the Fast Healthcare Interoperability Resource (FHIR) standard to facilitate the necessary data exchange.

The healthcare industry is under pressure to get more accurate price estimates to patients before they select medical services, particularly because of recent federal legislation, such as the “No Surprise Act of the Consolidated Appropriations Act,” for which an interim final rule was released on July 1. The regulations will take effect for healthcare providers and facilities on Jan. 1, 2022. For group health plans, health insurance issuers and FEHB Program carriers, the provisions will take effect for plan, policy, or contract years beginning on or after Jan. 1, 2022.

The Da Vinci working group for Payer Cost Transparency (PCT) thus is on a fast track to develop an implementation guide – after an initial public meeting in June, the team hopes to pull together a first version of a Standard for Trial Use (STU1) that can be balloted. Comments submitted as part of that balloting process will enable the standard to be further refined and improved.

The ability to determine a somewhat accurate estimate of the cost of care before delivery has always been nearly impossible because of the number of variables involved, such as whether multiple providers are involved in care, the extent of discounts payers have with those providers, whether they are in or outside a payer’s network, which supplies are used, and more, said Da Vinci Project members.

The inability to provide estimates makes it difficult for consumers to comparison shop or for anyone to estimate the value of services ultimately received by patients.

Recent federal laws and subsequent regulations exemplify the importance of developing a PCT implementation guide for providers and payers. The push is on to develop a FHIR standard that meets the need to share a Good Faith Estimate for the costs and codes for planned services and provide an Advanced Explanation of Benefits (AEOB) back to the patient prior to patient care while reducing the additional burden on providers and payers to do so.

Providers need this type of information as well, and payers need to align with claims processing needs so working with existing technology is a key piece of the solution. Da Vinci initiatives such as this aim to meet the industry where it is today while advancing the industry forward in ways that achieve value-based care goals through improved information sharing and efficiency gains.

A version of this story previously ran in the HL7 Quarterly Newsletter.

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