Patient Cost Transparency (Da Vinci project; PSS in Confluence)

Description

This PSS builds on existing implementation guides for the automation of coverage discovery (Coverage Requirements Discovery - CRD) and the Health Record Exchange Library/Framework (HRex) to provide cost information for planned or potential services/devices at the point of care when treatment decision are being made..

Payer automated capabilities that provide timely, robust pricing transparency between payers and providers, as well as payers and patients, is an industry priority Robust payer pricing transparency presented prior to the delivery of services will enable patients with their clinicians guidance to make informed decisions on their course of treatment and the cost to the patient

Patients need accurate, timely access to cost of medical care prior to delivery of care in order to become better stewards of their healthcare dollars. Exposing cost of services/devices and calculated Care Plan Pretreatment Estimate within an EMR workflow can lead to clinician/patient care plan decisions with increased patient adherence

Providers need accurate, timely access to pricing transparency prior to and immediately after delivery of pharmaceutical/medical care to collect financial responsibility from patients at the practice check out, immediately after providing care to increase patient responsibility collection and reduce collection costs.

This IG will define a simple exchange for providers to request and receive cost information from payer to enable clinician and patient medical device / services / medical care conversation.

This project will utilize specific triggers and exchange methods (CDS Hooks, Pull, etc.), use of other interoperability 'standards' (e.g. SMART on FHIR, CQL) and specific use of FHIR resources to effectively request cost information from the responsible payer and return it in real-time to the provider so they can use it in treatment planning conversations with their patient at point of service.

This project will reference, where possible the 'standards' defined by the Health Record exchange (HRex) Library/Framework Implementation Guide which in turn will utilize prior work from Argonaut, US Core and QI Core effort for FHIR DSTU2, STU3, and R4 where appropriate.

The ultimate goal is to support the request for cost information for specific services from the payer and return them in real-time to allow effective decision making by the patient in consultation with the 'ordering' provider.

he project team plans to work with existing FHIR artifacts where possible. If changes are necessary, the project team will work with the responsible Work Group to review and implement (via tracker items or new PSS) any necessary enhancements to base FHIR resources, extensions, and/or profiles.

Misc Notes
2025 Oct: TSC approved an STU Publication Request for HL7 FHIR® Implementation Guide: Patient Cost Transparency, Edition 2 - US Realm for 2 years 2025 April: TSC approved STU Extension Request for Patient Cost Transparency, Release 1.1 - US Realm for 6 months 2023 February: TSC approved STU Publication Request for Patient Cost Transparency, Release 1 - US Realm for 2 years External Vocabularies: HCPCS, SNOMED, CPT, ICD, RxNorm, LOINC For FHIR IGs and FHIR Profiles, what product version(s) will the profiles apply to? R4, STU3, DSTU2 Other Stakeholders and Providers: Federal Healthcare Agencies (e.g. CMS), Providers (e.g. Physicians)