The healthcare industry is being pushed towards greater transparency, and a new driver of this change is the Presidential Executive Order Empowering Patients through Radical Price Transparency. This order mandates that patients have access to actualprices for healthcare services, rather than just estimates. The Da Vinci Patient Cost Transparency (PCT) Implementation Guideoffers payers and providers a structured approach to comply with this requirement while enhancing interoperability and patient experience. The order also covers Prescription Drug Pricing. This in turn may see wider adoption of the CARIN Alliance’s HL7 FHIR Implementation Guide for Real-Time Pharmacy Benefit Checks (RTPBC). RTPBC is already a requirement in California and Texas and OnyxOS has implemented a solution for payers in those states.
The Price Transparency Challenge
Historically, healthcare pricing has been opaque, with patients often receiving vague cost estimates or being unaware of their financial responsibility until they receive a bill. The Executive Order builds on the No Surprise Act and seeks to eliminate this uncertainty by requiring:
- Clear, upfront pricing of medical services and procedures.
- Seamless data exchange between providers and payers to ensure accurate cost calculations.
- Real-time access to out-of-pocket cost information for patients.
However, achieving this level of transparency requires a standardized approach to data sharing—something that the HL7 Da Vinci PCT and CARIN RTPBC Implementation Guides helps facilitate.
How the Da Vinci PCT Implementation Guide Helps
The Da Vinci PCT Implementation Guide, built on the HL7® Fast Healthcare Interoperability Resources (FHIR®) standard, provides a structured method for real-time cost estimation and data sharing. Here’s how it helps:
1. Enabling Real-Time Cost Calculations
The guide supports the automation of cost transparency requests, allowing payers to calculate precise, patient-specific costsbased on real-time data. The Executive Order will drive the Good Faith Estimates (GFE) gathered from providers to be combined into an Advanced Explanation Of Benefits (AEOB) that will enable providers and payers to work together to provide an accurate cost to prospective patients.
2. Facilitating Coordination and Seamless Data Exchange
Using FHIR-based APIs, the Da Vinci PCT Implementation Guide enables payers and providers to exchange claims, benefits, and prior authorization data efficiently. This eliminates delays and ensures that patients have access to accurate pricing information before care is delivered. The PCT Guide goes further and provides mechanisms to facilitate coordination amongst multiple providers that may be required in order to carry out the requested service.
3. Improving Provider and Patient Decision-Making
With access to accurate pricing data, providers can discuss cost-effective treatment options with patients, leading to:
- Better-informed healthcare choices for patients.
- Improved financial planning, reducing unexpected medical bills.
- Higher patient satisfaction, as they can compare costs across providers.
4. Supporting Regulatory Compliance
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) also mandates the use of standardized APIs for patient, provider, and payer data sharing. The Da Vinci PCT Implementation Guide helps organizations align with these requirements, ensuring compliance with evolving federal regulations. The PCT Guide utilizes the FHIR Explanation of Benefit profile for the AEOB. the EOB profile is already exchanged with Patients via the Patient Access API and therefore the AEOB should be able to be made available to health plan members via the existing Access API.
5. Reducing Administrative Burden
By streamlining cost calculations and data exchange, the guide helps reduce manual interventions and administrative complexity. Providers no longer need to engage in time-consuming back-and-forth communication with payers to estimate patient costs.
Conclusion
The Da Vinci Patient Cost Transparency and the CARIN RTPBC Implementation Guides are critical tools for payers and providers striving to comply with federal price transparency mandates. By leveraging FHIR-based APIs, it enables real-time cost estimates, enhances interoperability, and improves patient decision-making. As healthcare shifts towards value-based care and consumer-driven decision-making, implementing these guides is a proactive step toward compliance and patient empowerment. The OnyxOS Interoperability Platform provides support for PCT and RTPBC enabling payers to move quickly to improve price transparency for their members.
Would you like help integrating this framework into your payer or provider systems? Reach out today!