Stream: implementers
Topic: Claim.insurer
Mattias Flodin (Jun 07 2017 at 12:30):
Hi, I'm surprised by the specific use of the word "insurer" in the Claim resource. Doesn't FHIR support billing other organizations than insurance companies?
Where I live it's very common for hospitals to send patients to other hospitals, and billing would then be performed between hospitals. Since we have universal health care it's rare that an insurance company is involved.
Lloyd McKenzie (Jun 07 2017 at 16:37):
The claim resource certain should support invoicing entities other than insurers. Can you submit a change request?
Paul Knapp (Jun 07 2017 at 16:38):
Billing is the provision of a request for payment for goods and services to the party directly responsible for payment - typically the patient or their guardian. A Claim is communication of a patients bill to a third party who may by virtue of their agreement with the patient reimburse the patient for some portion of those costs either directly to the subscriber to the insurance or to the provider of those goods or services via assignment of benefit.
Where you have universal healthcare usually that healthcare program is insuring the patient, will only pay for services to limits specified under that agreement (for example may only pay for a shared hospital room) and will directly make its payment to the provider, and therefore is the Insurer.
A Bill to a patient, or their guardian, for the balance of costs after netting off any assignment of benefit by insurers is not currently covered by FHIR resources.
Paul Knapp (Jun 07 2017 at 16:40):
Billing between suppliers and providers is handled by other SDOs such as EDIFACT.
Andy Stechishin (Jun 07 2017 at 16:44):
@Mattias Flodin what jurisdiction are you in? I myself am in a jurisdiction with 'universal healthcare' and I can assure you that claims to insurers is very much the normal processing. In my personal case the primary insurer is the Province of Alberta (Canada). However if I were to be injured in an acident at work, certain items would have the primary insurer as the Worker's Compensation Board follwed by the Province of Alberta. This is all exclusive of any additional private insurance I may have to cover such items as a private room.
All of these organizations play the role of insurer.
Andy Stechishin (Jun 07 2017 at 16:45):
@Lloyd McKenzie in the domain of finance and accounting, claims and invoices are very distinct concepts. YOu should be very careful not to confuse them.
Mattias Flodin (Jun 09 2017 at 07:36):
@Andy Stechishin I'm in Sweden. Economically each hospital is part of the county administration, which taxes its citizens to finance healthcare. When citizens in one county receives care from a hospital in another county, an invoice is sent between counties. But normally there's no insurance company involved.
@Paul Knapp so do I understand correctly that there's no FHIR resource to represent such an invoice?
Andy Stechishin (Jun 09 2017 at 13:46):
@Mattias Flodin some jurisdictions do not use an insurance approach to healthcare payments, in which case you would not use Claims (please note, my healthcare is also paid through taxes but the government acts as an insurer). Does Sweden not allow private insurance plans for items such as drugs, dental, private hospital rooms, ambulance, and physiotherapy?
Mattias Flodin (Jun 09 2017 at 13:57):
@Andy Stechishin Sure Sweden allows it, there's no law against providing private healthcare. But in that case it's entirely handled outside of the county organization that I work for. There are also private healthcare providers that have a contract with the county for universal healthcare, and in that case they will bill the county for provided services.
Andy Stechishin (Jun 09 2017 at 14:09):
@Mattias Flodin nothing would prevent you from using the Claim for your purposes, you would just create a profile that removed insurer (it is 0..1) but you could also look at ChargeItem
Mattias Flodin (Jun 12 2017 at 06:56):
Ah thanks @Andy Stechishin . ChargeItem looks interesting, I had missed that. In the case of Claim though, even if I remove insurer I would still need an attribute to describe who is the receiver of the invoice.
Paul Knapp (Jun 13 2017 at 17:18):
@Mattias Flodin You would be looking for a Bill not a Claim, and for the supply of goods and services I think that would be a collection of charges (ChargeItem in FHIR, FT in v2). That resource has not been modelled as yet.
With respect to the universal healthcare paying providers for services rendered to members of the universal healthcare program - the universal healthcare program is insuring the program member and therefore serving as the insurer and reimbursement is via a Claim, but in the relationship between a provider and another provider (or supplier) this is a goods/services purchase arrangement and therefore a Billing arrangement.
Mattias Flodin (Jun 14 2017 at 06:42):
@Paul Knapp I'm a little confused, what do you mean by the resource not being modelled yet? Do you mean that ChargeItem is still a draft? Because I do see a bunch of attributes in the documentation for it.
Peter Scholz (Jun 14 2017 at 07:41):
@Mattias Flodin But for now, ChargeItem is still maturity level 0 . And there is still plenty of discussion going on about invoices
Paul Knapp (Jun 14 2017 at 15:17):
ChargeItem is a draft (FMM 0), actually none of the specification or resources are currently normative although we expect to take some to normative ballot in May 2018. FM hasn't developed a Bill in the past given the wealth of existing billing and financial systems, rather we provide the information for the billing systems to use, for example: Financial Transaction in V2 and ChargeItem in FHIR. HL7 doesn't develop specifications for AR/AP/GL or inventory systems.
Paul Knapp (Jun 14 2017 at 15:32):
@Peter Scholz So that I'm not assuming, by invoices are you referring to claims (my guess) or bills (what Mattias wants)?
MaryKay McDaniel (Jun 14 2017 at 16:38):
Hi all,
I was just reading this thread and had a 'business side' view of the conversation that may (or not) be helpful.
The basic use case for "a claim" was a document to be used by the "servicing" provider that could be submitted to a payer to facilitate payment for the services or the products used in those services. And the basic use was between the provider and the payer. In all cases when we talked about the 'claim' we defined the payer as an Insurance Company or Social Health Program (Medicaid in the US).
We touched on the concept of one provider 'billing' (or charging or invoicing) another for for services performed for a service that the 'originating' provider then "claimed" from a payer. i.e., Hospital A sends Patient A to Hospital B for a specific procedure - for whatever reason (Hospital A doesn't /didn't have the equipment, the equipment was not working). Hospital B then bills Hospital A for the services performed. Hospital A bills the 'insurance company' (Payer) for all services performed. We did not specifically create the use case and model it. This was the use case we did not have any experience with.
So, could there be a way to do it using the existing FM V2, V3 or FHIR messages, artifacts, resources? I'd make a SWAG that there probably is. Would it include all the necessary details, no clue. If this is an actual business need and we have interested parties in working through it, then I'd like to sit down and put together the use case and then take it from there.
Thanks!!
Mary Kay McDaniel
Peter Scholz (Jun 14 2017 at 17:03):
@Paul Knapp There will be no difference, an invoice is an invoice regardless wether it is for health services and sent to an insurance.
So it is both and there is no need for a difference (at least in Germany)
Andy Stechishin (Jun 14 2017 at 17:05):
@Peter Scholz Invoices and and claims are very different financial concepts in the majority of financial jurisdictions. Germany may be different in that regard but then they are definitely not in the 80%
Peter Scholz (Jun 14 2017 at 17:08):
@Andy Stechishin That is correct, claims and invoices are different financial concept, but charging health services to a health insurance are invoices an no claims here (and as I would guess in lots of other countries as well)
Lloyd McKenzie (Jun 14 2017 at 17:09):
FM needs to clearly define whether the Claim resource is intended to cover invoicing or not. If not, a separate resource to meet the use-case is required. In either case, a solution needs to be provided.
Peter Scholz (Jun 14 2017 at 17:10):
@Lloyd McKenzie true
Andy Stechishin (Jun 14 2017 at 17:10):
@Peter Scholz unfortunately your guess would very much be incorrect seeking payment from health insurance providers is not invoices in most other countries
Andy Stechishin (Jun 14 2017 at 17:11):
@Peter Scholz @Lloyd McKenzie it is obvious the resource is called Claim not Invoice, how more plain could it be?
Andy Stechishin (Jun 14 2017 at 17:12):
please refer to @MaryKay McDaniel previous message
Peter Scholz (Jun 14 2017 at 17:15):
@Andy Stechishin @Lloyd McKenzie then we will definitely need a separate resource. We (HL7 Germany) came already to that conclusion during our meeting this week .
Andy Stechishin (Jun 14 2017 at 17:16):
@Peter Scholz again I refer you to @MaryKay McDaniel 's previous note. Bring it forward and I am sure FM will be happy to see it get moving
Peter Scholz (Jun 14 2017 at 17:19):
@Andy Stechishin we are working on it .
Paul Knapp (Jun 14 2017 at 17:25):
The above comments about claims vs invoices are correct, and some may need an invoice rather than a claim.
@Peter Scholz For my understanding, when you send an invoice for services to whomever will pay it, they and only they pay the invoice and they pay it completely (unless they dispute some line items)?
Peter Scholz (Jun 14 2017 at 17:26):
@Paul Knapp Yep, that's the way it is.
Paul Knapp (Jun 14 2017 at 17:27):
So the provider works for the payor not the patient?
Paul Knapp (Jun 14 2017 at 17:36):
@Peter Scholz Then that should be a separate resource as there is a significant difference to: the intent; the content required; and, the response content as well.
Paul Knapp (Jun 14 2017 at 17:52):
@Peter Scholz Do you have a specification for how the invoice is constructed today? I'd prefer in English but I can work with German.
Last updated: Apr 12 2022 at 19:14 UTC
