What we don't do
Flexpa is the simplest and easiest way to connect your patients' claims data, which can power a number of use cases across healthcare, benefits, and fintech. However, claims data is not always what you're looking for. Rather than try and square peg a round hole, we want to make sure you're equipped with the right tools to solve the right problems from the wide range of inteoperability and API products on market today.
Below are some other common interoperability problems that organizations in healthcare face and some of the solutions available today to help you.
Provider Data
A clean list of providers and organizations is actually surprisingly hard to come by. Providers switch organizations, change addresses, and change names. Organizations are merged, acquired, and closed as a stunning related.
For your use cases and problems, you may need to know the provider's name, address, phone number, taxonomy code, and NPI. You may also need to know the organization's name, address, phone number, and taxonomy code. While Flexpa includes some provider data in our claims data, such as a patient's prescribing provider for a MedicationRequest resource or a patient's attending provider for an Encounter resource, a full foundational list of providers and organizations may be beneficial.
The CMS has the National Plan & Provider Enumeration System (NPPES), which is a free data set, but it is not always up to date. They offer a bulk download, an API, and a user interface to interact with provider data.
There are also a number of commercial solutions that provide provider data:
Flexpa claims data is a powerful tool alongside price transparency data in that they form two of the main three factors (a correct list of providers, a list of available services and costs, and prior healthcare usage) to help patients properly plan and navigate their care.
Price Transparency and Cost Data
Understanding providers and organizations is only the first piece of the puzzle. Patients and vendors also need to know what services these providers offer and how much they cost. Thus, we stumble upon the raison d'être of price transparency.
Between the trifecta of legislation and regulation of the CMS Hospital Price Transparency, the CMS Transparency in Coverage Rule, and the No Surprises Act, price transparency is a hot topic in healthcare. For further detail, we recommend this summary here.
These rules mean that all hospitals and payers must publish their price transparency data in a machine-readable format. This data includes a list of services and their costs. This data is available for free and can be used to power a number of use cases.
However, these are large files and often difficult to track down. This open source initiative is a great resource for processing price transparency data.
There are also a number of commercial solutions that aggregate, normalize, and provide value-add services on top of this data:
Flexpa claims data is a powerful tool alongside price transparency data in that they form two of the main three factors (a correct list of providers, a list of available services and costs, and prior healthcare usage) to help patients properly plan and navigate their care.
Eligibility
Understanding if a patient is eligible for a given service or benefit is the first step on the critical path to providing care and later receiving reimbursement. Claims clearinghouses and eligibility verification services are the most common solutions for this problem.
Flexpa claims data can be powerful to augment eligibility data, as it can provide a more complete picture of a patient's benefits and coverage. For example, Flexpa claims data can help you understand a patient's spend towards their deductible or improve your success rate of predicting the actual cost, reducing backend administrative time for corrections to bills.
Networks
Claims clearinghouses act as hubs that allow healthcare practices to transmit electronic transactions to insurance carriers in a secure way that protects patient health information, or protected health information. These networks are some of the oldest and most ubiquitous in the healthcare industry and are used by all types of healthcare providers, including hospitals, clinics, and individual practitioners. At this point, they have broad coverage to almost all payers, as many clearinghouses have data exchange agreements with one another.
As a result of the HIPAA transaction rule, clearinghouses are required to use the X12 standard, which can be challenging to implement and maintain. As a result, today eligibility requests are primarily serviced through clearinghouses using that standard.
Some examples:
On-ramps
X12 is an old and difficult standard, so a number of companies have built on-ramps to make it easier to use. These on-ramps are often built on top of the X12 standard and are used to translate X12 into a more modern format, like JSON. This makes it easier for developers to build applications that can consume eligibility data.
These on-ramps have an additional cost on top of any clearinghouse network fees. However, they can be a good option for developers who are looking to build applications that consume eligibility data that are looking to move more quickly.
Some examples:
Clinical Data
Aggregating a patient's clinical history from other providers is a critical step in providing care. This is especially true for patients who have complex medical histories and are seeing multiple providers. For example, a patient with diabetes may be seeing a primary care physician, an endocrinologist, and a nutritionist. In order to provide the best care, these providers need to be able to access the patient's full medical history.
Flexpa claims data from payers can be powerful to augment clinical data from providers, as it can provide a more complete picture of a patient's care. For example, Flexpa claims data can help you understand whether care was provided in-network or out-of-network, which can help you understand the patient's total cost of care.
Networks
Health information exchanges (HIEs) and health information networks now exist at both regional and national levels. These networks are designed to allow providers to securely exchange clinical data with one another.
These networks are often built on top of the C-CDA standard, an XML format, and use a query (search and retrieve) model for pulling data. Given that they are most useful with a treatment purpose of use, they are really only usable today for provider organizations or business associates of provider organizations involved in the treatment process, such as EHRs. They also typically require reciprocity - that is, providers must respond to queries from other providers with their unique clinical data in order to retrieve data from others.
Some examples:
On-ramps
C-CDA is a complex standard, so a number of companies have built on-ramps to make it easier to use. These on-ramps are often built on top of the CDA standard and are used to translate CDA into a more modern format, like FHIR or JSON. This makes it easier for developers to build applications that can consume providers' clinical data.
These on-ramps have an additional cost on top of any HIE or HIN fees. However, they can be a good option for developers who are looking to build applications that consume provider clinical data that are looking to move more quickly.
Some examples:
We'd love to discuss more about how claims and other payer data can fit alongside and supplement these other solutions, so contact us to chat!