CMS-0057 Payer-to-Payer Connectathon
Flexpa is hosting a webinar on patient consent and payer-to-payer data exchange on March 12th. Join us to learn how the industry is tackling consent management, network connectivity, and data standardization. Save your spot now.
After participating in the most recent HL7 Connectathon on the PDEX track I have a few thoughts that change how I am thinking about PDEX and specifically Payer-to-Payer connections.
The First Problem is Consent
In talking to many payers and vendors, the first thing that comes up in talking about CMS-0057 is the concept of consent. We are all familiar with the idea. Usually, we experience this in the medical world via signing a paper. CMS-0057 and Payer-to-Payer specifically require digital consent. This isn't something that a lot of Payers or even Vendors have figured out. Consent is a really important step in centering the exchange of Healthcare data around the desires of the human to whom those records belong.
In order to bring the patient to the center it requires more patient-facing infrastructure. How does a patient generate consent? How do patients adjust and revoke consent? How do endpoints validate consent? How do payers trust provided consent?
Much of this space is completely new to payers impacted by CMS-0057 and there are no real solutions in place yet.
CMS-0057 is not prescriptive about the process or procedures payers will need to use to gather consent, but in many ways a blank slate is worse than a highly prescriptive one because it requires impacted payers to figure it out for themselves:
If payers believe that a patient portal or mobile smart device with appropriate security protections is the best way to gather opt in, it is permissible to use those methods. We are not being prescriptive about the process or procedures used by impacted payers for the required opt in process. However, we strongly recommend that there be a way for patients to record their permission telephonically or otherwise if they do not have internet access or do not want to sign up for an electronic portal. We agree that equitable access to patient data is of the utmost importance and emphasize that the Payer-to-Payer API requirements are intended to allow for other solutions besides patient portals for authentication, verification, or consent.
(Source: CMS-0057)
Networks Are Hard
In order to make a request to fetch historical claims data, we will need to know:
- Who does this request go to?
- Where is their FHIR server?
- How do I register a client to pull data?
These questions, and all the humans in the middle of answering them make it really difficult to see a path forward on making requests in a Payer-to-Payer network.
TEFCA, FAST National Healthcare Directories, a Github repository, or some combined amalgamation of all the above may solve some of the discoverability problems. Bundle the discoverability solution with something like Unified Data Access Profiles (UDAP) and you may be able to answer questions 1-3. These solutions are evolving and growing but will they be developed quickly enough to help payers be quick movers in the Post-CMS-0057 market? It's hard to tell if the solutions will be ready or if they will get adopted.
Data Are Like Bellybuttons
Part of the difficulty of the network is the diversity of opinion on how data is structured, accessed, validated, and shared. Each of the payers in the network offers another opportunity for data variance. This variance is reduced when exchanging data between 2 nodes using the same vendor but it still exists (ask me how I know 😅).
Understanding the data coming across the network is not trivial. Based on our experience, even understanding what Providers a member has seen or what medications they have been prescribed are not simple to answer based on data from many organizations. It requires understanding each node on the network and being able to devote some time to customize the data retrieval based on the node. Understanding and being flexible enough for every node on the network is difficult.
Payer-to-Payer is More Than Compliance
Most vendors are focused on helping teams set up the compliance side of the payer-to-payer requirements in their solution. If all the payers simply meet the requirements of having an API then this work won't actually have any benefit. Compliance requires payers to be able to respond to these requests but the value is in making requests to other payers.
I think it would be outrageous to miss out on experiencing the value of getting additional, structured, historical claims data at the point of enrollment.
There is some additional work needed to be able to make requests instead of just responding to them, but I think the lift is substantially smaller. This leads into my next thought.
What if?
What if there was a company that has been working on Digital Consent for years already? What if they were experts in collecting, managing and verifying digital consent?
What if there was a company that already had a network that included connections (human and computer) to nearly every payer in the US?
What if there was a company that has already invested in understanding how records change from one payer to the other and has built a pipeline to help answer real questions using that data?
Flexpa
Flexpa has answers for all of these questions.
Digital Consent Pioneers
We have collected, managed and verified digital consent since the beginning. We've never done it a different way.We built for digital consent from day one—it’s in our DNA (“Flexpa” stands for Flexible Patient Access). We already process 10,000+ successful consents monthly using our purpose-built, modern, digital-first, member experience. We have a proven solution for collecting, storing and managing patient-driven, digital consent.
Our consent product can be used in-app, as a third-party or in an out-of-band workflow like email, text or chat.
Real-world Network Success
Flexpa has the industry's largest payer FHIR network: 331 unique, production-ready servers with direct connections to 383 MCOs. Each of these integrations were built with our technical know-how and the help of Vendor and Payer teams across the US. We have battle-tested integration experience with every major payer in the US. We implement new payer connections faster than anyone else in the industry.
Why waste time making connections to all the other payers when we have already built the Network? Implement new connections with minimal IT resources involved and operate on our Network.
Record Winning
Flexpa has processed millions of FHIR resources across hundreds of payers. Not only can we get patient records, we work with individual payers to understand data variance and normalize structure. That way, payers using our Records product get predictable data. Do you want realtime records? Great! Want to pull them into your system via an ETL? Perfect. Want webhook calls when records are available? Excellent.
No matter how you look at it, Payer-to-Payer is unlocking some unique opportunities to gain access to Patient-consented claims data. Don't get tripped up figuring out consent, the network or the records.
In March, join us for further discussion of these topics in a public industry webinar we are hosting on patient consent and payer-to-payer data exchange. Save your spot now.
