[TPA Trends] What is HL7 FHIR and Why is this Important for Benefits TPAs?

Hl7 Fhir 1 Scaled

When it comes to the transferring and sharing of medical data, security is paramount. As integrations between systems become more and more common, we must rely on trusted standards and security measures to ensure the safety of this sensitive information.

Patient access is an approach to exchanging health information where patients can obtain their claims and clinical records and grant others access to those records electronically. New APIs are being built using HL7® FHIR® to support access to these records.

Fast Healthcare Interoperability Resources (FHIR) is a set of standards created by Health Level 7 (HL7) that mandates healthcare data interoperability standards. In this TPA Trends article, we’ve broken down everything you need to know about HL7 FHIR, including recent changes and how they will impact administrative processes for Benefits TPAs. 

In this post:

Introduction to HL7 FHIR

The accessibility of healthcare data has become a growing priority in recent years starting with the legislation as part of the 21st Century Cures Act. Following this legislation, the CMS (Center for Medicare and Medicaid issued the CMS-9115-F, “CMS Patient Access Final Rule.” This made insurance and clinical data available to patients (and others they allow) electronically via SMART on FHIR. Any commercial insurance plan that worked with CMS needed to adopt this and make patient access data available for all Medicare and Medicaid plan types. This greatly accelerated the adoption of HL7 FHIR across the healthcare industry. 

With the standards set by HL7 FHIR, some insurance are even making commercial APIs available (like Anthem, who we recently announced support for their Patient Access API on the TPA Stream platform). The recent adaption of this data standard has set off a flurry of innovation in the healthcare segment, but what has been largely untapped, however, is how HL7 FHIR can also streamline the work of Benefits TPAs for employee benefits.

What is HL7 FHIR?

HL7 FHIR is a set of standards, rules, and formats for transferring and sharing medical data between systems. HL7 FHIR standards aim to unlock healthcare data to make it more easily accessible on multiple systems and to multiple parties with the patient at the center: who can easily access their medical record information and authorize access to others.

Compared to previous standards, HL7 FHIR delivers higher automation capabilities and enhanced ease of use. In dated, document-based healthcare information infrastructures, sharing information between parties was limited and laborious due to its static nature. The HL7 FHIR is modeled after the internet and offers a streamlined approach to the accessibility and administration of healthcare data with advanced capabilities compared to its predecessors. 

Using HL7 FHIR for healthcare interoperability enables better outcomes for patients and benefits administrators alike. Patients and their healthcare providers can more easily share healthcare data necessary to make informed decisions, while benefits companies and TPAs can utilize the advanced systems to streamline their work processes. For example, streamlining a Benefits TPA’s claims harvesting process can help to make informed decisions on benefits and find benefit cost-saving opportunities.

Why is Everyone Talking About HL7 FHIR?

As of December 31st, 2022, healthcare providers are now mandated by the Office of the National Coordinator for Health Information Technology (ONC) to implement HL7 FHIR APIs. The Centers for Medicare & Medicaid Services (CMS) mandated that Patient Access APIs be used by all health plans that receive funding for Medicare and Medicaid. They also recommend to all companies and entities that they adopt the data standard. This effort, aimed at improving the access and exchange of healthcare information, carries major impacts for patients, benefits companies, and third party administrators (TPAs) alike.

With the increased demand for healthcare interoperability and these recent mandates, HL7 FHIR has become a trending topic that carries major impacts on both patient care and employee benefits. Major healthcare organizations have begun adopting, and widespread uptake is expected by 2024. The time is now to dig into the impacts this data-sharing innovation will have on benefits administration. 

As a TPA, staying informed about this major shift in healthcare data exchange enables you to adopt new practices that better serve your clients and empower you with increased automation and features. Better yet, advances like HL7 FHIR streamline your processes and allow you to maximize the value you deliver to clients while lowering your workload and eliminating unnecessary clerical work. 

HL7 FHIR and Benefits Companies 

Benefits companies like third party administrators, brokers, and app developers can benefit from the trend toward more aligned data sources like FHIR. Providers of insurance, flexible spending accounts, and health savings accounts can use this claims data for streamlined claims processing, plan qualification, debit card substantiation, plan evaluation, or consumer applications like medical bill negotiation.

The cost of getting a direct carrier feed from a particular insurance carrier is cost prohibitive, hard to manage, and often inconsistent from carrier to carrier. Today, many TPAs work with TPA Stream to get participant-level consent for claims. With more carriers moving to FHIR, there will be increased attention on how these claims enable next generation benefits. The market for new applications that can consume one API is going to grow.

Case Study – Anthem Patient Access API

HL7 FHIR offers advantages for all parties involved in healthcare data exchange. Fast, accurate information-gathering, billing, and claims harvesting allow benefits companies and TPAs alike to enjoy a better experience while focusing their efforts on what matters most: providing the best experience to their customers. With this greater access to data, you can more easily extrapolate the information you need to facilitate simplified billing and claims management.

As TPAs strive to deliver value with swift and accurate support, the software platform they choose impacts their ability to best serve customers. At TPA Stream, we’re committed to providing TPAs with innovative solutions that facilitate stronger customer relationships. We are continuously advancing our claims data and benefits software to embrace new possibilities that innovations like the HL7 FHIR bring. 

Recently, we introduced Anthem Patient Access API to our platform, enhancing deliverability and connectivity so TPAs can increase the level of service they provide to their customers. Our comprehensive integrations support better healthcare interoperability and empower TPAs to maximize the value they offer in smart, streamlined ways. As healthcare interoperability evolves and grows, TPAs can count on our innovative software to grow with it.

Challenges and Future of HL7 FHIR

HL7 FHIR is revolutionizing how we share and access healthcare data, but this revolution comes with unique challenges in the early stages. Delays in implementation are to be expected and security remains a top priority to ensure the enhanced data exchange remains safe and protected. There may also be a learning curve to adopting new standards and processes, and current member participation needs to improve. 

Despite these initial challenges, the future is promising, and the benefits we stand to gain are grand. Benefits companies can achieve cost-saving measures without compromising on providing personalized, enhanced benefits to their users. Patients and their providers are empowered to achieve better healthcare with the ability to access all necessary information and make real-time medical decisions. Patients are in control over who can access their information. 

For Benefits TPAs, increased access to healthcare data facilitates a streamlined benefits administration and claims process. Have comprehensive data you need to make informed benefit decisions every time.

Contact TPA Stream for Better Data Solutions

At TPA Stream, we’re proud to support TPAs with better data solutions. From streamlined Employer Invoicing to benefits and Claims Harvesting software, get the tools you need to automate manual work processes, improved the participant experience, and win market share. Contact us today to learn more how our innovative solutions will support you.


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