20240626 - Da Vinci PCT STU2 Ballot Reconciliation.pptx
Today, 6/26, we will come back to an open discussion on the feedback related to the connection between the Coordination Workflow & GFE Submission -Jira grouping “Submission”
Tickets aligned:
- FHIR-45852- Misapplication of convening provider requirement
- FHIR-45931- Delete – not established by regulation. &FHIR-45854- Issue with information flow between business actors
- FHIR-45853- Purpose of IG
- FHIR-45851- Clarification regarding convening provider
- FHIR-45912- Convening provider
- FHIR-45928- Do not presume convening provider model for insured patients
Add clarification regarding the connection between the Coordination and GFE submission workflows
- FHIR-45868- Add guidance on GFE Collection Bundle differences for coordination workflow and submission
- FHIR-45736- Can the Coordination Platform also send the Bundle to the Payer?
Corey reviewed the deck slides 5-10 on what is in the IG today and the associated tickets received during the ballot period.
A few key points:
The mechanical change to a bundle of bundles in the GFE Submit simply allows that one or more providers' GFEs could be submitting. the ability to submit one GFE from one provider is still supported.
Andrea - is continuously taking issue with tech onvening provider inclusion in the use case. Requiring the diagnosis code in the GFE
Getting ahead of ourselves with including the convening provider being included beyond the self-pay/uninsured use case prior to regulation that requires it. Celine agrees.
AP: We recognize there must be a triggering event and quote a "convenor" for this to occur, but the language of using convening provider in the IG is getting pre-maturely or mis-applied at this time.
CS: Agrees we should not be using the term and therefore the IG should be using technical actors for roles in the operation, rather than the regulatory words.
Want to look more closelyt at the details for where the convener provider in the AEOB use case.
SU (BCBSA) - Agrees in spirit but will offer an alternate view for the record. The GFE is aligned with the the 279VB-6? is the strongly wording - not sure we can not expect the same things for both of these.
DSC: There is just one section of the law for the GFE and it triggers either the GFE to patient or to Payer - it's the same GFE, in the law. so from a facilitation in getting the GFE together, the legal expectation is that it is the same GFE.
AP: appreciates the distinction on the technical actors and the law language of "convening provider" since there is a difference in the use cases.
We have outlined the output of the coordination so that it can be used for the
It's aligned with expectations that the output of GFE is the same whether there are one or more providers and whether the GFE is going to the patient or the payer, to keep alignment and simplicity with the provider and facility process.
It's a semantic issue - the words and framing of narrative in a few locations. AMA and AHA are aligned in this being a semantics issue rather than technical, workflow, or anything else.
Action Item: Look through the diagrams to check for sematic updates needed.
FHIR-45931 - Getting issue details... STATUS - Reviewing this one. Need a business actor who serves the role.
A convening provider can chose to submit to a payer.
A convening provider always submits to a payer. The convening provider always submits
The concern is implying that the Convenor provider has to do this.
SU - the law already says they have to coordinate across providers. Thinking from the payer perspective, the co-provider sends it to the payer. they the other providers would have. There would have to be a tracking mechanism to pull them together. The convening provider if having to submit all providers
If everyone is breaking it up and then it will be problematic for patients to not see all their providers for one service together (out of pocket max will not be calculated correctly.)
SU reminds all of the conversations we had last year on different workflows and that we landed here. AMA and AHA are still concerned and uncomfortable with the language as is and any presumably.
Agreement that Patients deserve and want it all bunded together - Patients want to see the hold cost of the knee surgery.
Will review other tickets more holistically to make a recommendation for tweaked language based on the concerned of implication.
Looking at another ticket: FHIR-45853 - Getting issue details... STATUS :
Discussed edits as follows:
...In the overview, the IG states "By using the FHIR standard and implementing this guide, providers and payers can enhance their existing technologies, where applicable, for estimating patient costs securely and efficiently using common open web technologies. The anticipated benefit of using FHIR APIs is to streamline the process of creating a single comprehensive GFE for self-pay/uninsured patients and a single AEOB for insured to enable applications of the patients' choice to give greater transparency into patient-specific estimated costs of expected healthcare items and services by making AEOBs accessible."
FHIR-45851 - Getting issue details... STATUS - VC - want to be mindful that we don't clarify to specific uninsured/self-pay throughout the whole guide that causes additional updates when the regulation is made.
What would solve this for Andrea - not using the regulatory definition in the business actors section to make tat more clear.
Celine is not sure that we solve it with that one definition, but will take another look through the IG.
Want to enable providers and not create an inadvertent ceiling based on the law. we want to fix the bigger picture problem.
Celine thinks that is fair. Coordination workflow can only be applied to self-pay. That is not something we want to restrict down to.
SU (BCBSA) would a note in the business actors section something like:
Note: the term "convening provider" is being used to be consistent with the language in the self-pay/uninsured GFE regulations. In this IG, it is a role available for insured use cases, but whether it is required will be determined by future regulations.- Coordination is here for availability for all, but the regulation is for self-pay and for the
FHIR-45912 - Getting issue details... STATUS
Statutory provision for AEOBs cross references the provision for GFEs and they are tied together by the law. Any regulations that are written in the future are going to be constrained by those statutory provision. Do they all need to be tied together of if they need to hit the insureds system together as one bundle.
We want to be very cognizant about not stepping into policy. we want to enable capabilities and not do that.
FHIR-45928 - Getting issue details... STATUS - Corey raised this one and not sure it really presumes that. Celine feels if we clarify early on that it is not to be assumed, they that is fair and would be ok leaving this one as is or doing a collection or adding single.
Andrea and Celine both like the idea of solidifying that we are not presuming this for insured patients across the IG.
