Sorry if this is a obtuse question: it seems patients need to log in to their health plan portal to get their claims data (and per this report, get mixed results). My question is, can a patient instead get IAL2 verified and submit a request for their claims data without having to go through their plan portal? For clinical data this can be achieved without having to sign into the patient portal of the health system (Patient Request in Carequality, Individual Access in TEFCA). Is there an equivalent method for claims?
I realize the payers don't participate in the NNs today, and they may never. But my question was more around whether there is a service provider that manages connections with the many plans so that the patient could request (most likely through a consented proxy) their claims through one API call? And that path avoids them having to go through the plan portal?
FYI, Patient Request is no longer strictly hypothetical. We have been doing consented production patient request queries with a statewide HIE using the Carequality framework since early April. Now we need to get more participants expand beyond just the treatment PoU.
No, we'd love to see IAS for payers, but just like clinical data, the only ubiquitous route for patient access today is via portals. A couple of key differentiators:
1. Patients have one payer at a time (typically), so they are more likely to know or be able to recall their username/password
2. Payers support on-the-fly account creation (providers generally do not)
3. Digital account activation is higher for payers than providers
As a result, conversion rates are significantly higher for payers compared to providers (although vary across customer based on their value proposition, workflow, and patient demographics). Our best customer has an 86% conversion rate
TEFCA and IAS would be the mechanism for a trust based flow, with proper rules and payer participation gating.
A single HIE responding to patient request is great, but it's been the case for years that a handful of nodes respond to Patient Request. Until it's required to respond, it's not reliable to patients and there remains a strong incentive for companies to abuse Treatment. I'm optimistic on TEFCA as the vehicle for these paved paths.
Thanks for your reply, it is useful information. The only quibble I have with it is that while patients have one plan at a time, many patients get new plans every couple years as their employers continue to shop due to increasing prices. So there might be no way to get my claims data from last year or 3 years ago under this method. Requiring a specific memberid/password adds friction versus an identity-proofed requester, and it is significantly more hackable.
Username and password are the current friction (they don't add it). Removing that friction safely is the challenge (other parallel industries with data that cannot be just dumped in a big database, like banking, have not successfully done so at scale either). I'm optimistic we'll get there, but it's work to be done.
We're just in the business of offering what's the best possible way today - this path wasn't available before 2021, so even it is an upgrade for patients over previous status quo.
Hey Jerry! That may be the case for their claims processing infrastructure but not their patient access API. That's by Edifecs, which you can see clearly here:
great comments. thank you.
Sorry if this is a obtuse question: it seems patients need to log in to their health plan portal to get their claims data (and per this report, get mixed results). My question is, can a patient instead get IAL2 verified and submit a request for their claims data without having to go through their plan portal? For clinical data this can be achieved without having to sign into the patient portal of the health system (Patient Request in Carequality, Individual Access in TEFCA). Is there an equivalent method for claims?
Hey Glenn,
Two points here:
1. No payers participate in the health information networks today
2. Patient Request and Individual Access Services are still hypothetical as they aren't responded to on the networks today
I realize the payers don't participate in the NNs today, and they may never. But my question was more around whether there is a service provider that manages connections with the many plans so that the patient could request (most likely through a consented proxy) their claims through one API call? And that path avoids them having to go through the plan portal?
FYI, Patient Request is no longer strictly hypothetical. We have been doing consented production patient request queries with a statewide HIE using the Carequality framework since early April. Now we need to get more participants expand beyond just the treatment PoU.
No, we'd love to see IAS for payers, but just like clinical data, the only ubiquitous route for patient access today is via portals. A couple of key differentiators:
1. Patients have one payer at a time (typically), so they are more likely to know or be able to recall their username/password
2. Payers support on-the-fly account creation (providers generally do not)
3. Digital account activation is higher for payers than providers
As a result, conversion rates are significantly higher for payers compared to providers (although vary across customer based on their value proposition, workflow, and patient demographics). Our best customer has an 86% conversion rate
TEFCA and IAS would be the mechanism for a trust based flow, with proper rules and payer participation gating.
A single HIE responding to patient request is great, but it's been the case for years that a handful of nodes respond to Patient Request. Until it's required to respond, it's not reliable to patients and there remains a strong incentive for companies to abuse Treatment. I'm optimistic on TEFCA as the vehicle for these paved paths.
Thanks for your reply, it is useful information. The only quibble I have with it is that while patients have one plan at a time, many patients get new plans every couple years as their employers continue to shop due to increasing prices. So there might be no way to get my claims data from last year or 3 years ago under this method. Requiring a specific memberid/password adds friction versus an identity-proofed requester, and it is significantly more hackable.
Username and password are the current friction (they don't add it). Removing that friction safely is the challenge (other parallel industries with data that cannot be just dumped in a big database, like banking, have not successfully done so at scale either). I'm optimistic we'll get there, but it's work to be done.
We're just in the business of offering what's the best possible way today - this path wasn't available before 2021, so even it is an upgrade for patients over previous status quo.
Hey Jerry! That may be the case for their claims processing infrastructure but not their patient access API. That's by Edifecs, which you can see clearly here:
https://www.lacare.org/technical-information