Federal RFI and potential law have implications for FHIR

An RFI on the law without surprises asks for more guidance on a use case, while a law passed by the House could provide more impetus to automate pre-authorization.

An RFI from federal agencies and a rule passed by the House would encourage the use of FHIR to facilitate troublesome transactions.

Two recent federal policy developments focus attention on improving access to health care information and improving administrative processes, including prior authorization and patient communication.

Both initiatives provide broader opportunities for using the Fast Healthcare Interoperability Resources (FHIR) standard, said those involved with HL7 and its Da Vinci project, an accelerator that has worked to use FHIR to support healthcare initiatives. exchange of information facilitating transactions between providers and payers. .

In a development, the federal departments of Labor, Treasury and Health and Human Services launched a request for information (RFI) focused on advanced explanation of benefits and good faith estimates for those covered. These are requirements of the No Surprises Act – part of the Consolidated Appropriations Act of 2021. Certain aspects of the No Surprises Act present significant challenges for healthcare organizations to comply with the requirements to obtain appropriations. ‘accurate estimates of medical expenses for consumers before treatment.

“The Patient Cost Transparency Task Force continues to review and update draft standards based on public feedback received during the voting process.” Comments on the RFI are expected by November 15.

This RFI aims to obtain information and recommendations on the transfer of data from providers and establishments to schemes, issuers and insurers; other policy approaches; and the economic impact of implementing these requirements.

The request specifically calls out the potential for using the FHIR, APIs, and Da Vinci Patient Cost Transparency (PCT) use case efforts. It notes that Da Vinci “has started a patient cost transparency project dedicated to developing an IG that could be used to exchange AEOB and GFE information,” notes the RFI. The current version of the standard for trial purposes “is usable by the industry today, and the Patient Cost Transparency Working Group continues to review and update draft versions of the standard. based on public comments received during the voting process”. Comments on the RFI are expected by November 15.

Separately, on September 14, the House of Representatives passed HR 3173Improving Timely Access to Care for Older Persons Act 2021. The bill is now sent back to the Senate for further consideration.

The intent of this legislation is to accelerate seniors’ ability to receive quality care under Medicare Advantage by modernizing how Medicare Advantage plans and health care providers use prior authorization.

Prior authorization — which aims to reduce abusive payments and unnecessary care — has received a lot of attention because of the delays the process causes when providers and payers determine whether medical treatments will be covered.

The Da Vinci community has prioritized work on three use cases that aim to automate pre-clearance procedures – these are Coverage Requirements Discovery (CRD), Documentation Templates, and Rules of Procedure. Payer (DTR) and Prior Authorization Support (PAS). Those responsible for Da Vinci’s efforts claim that these use cases comply with the spirit of this law.

Ramon J. Espinoza