Stream: CARIN IG for Blue Button®
Topic: Paid from HSA account amounts
Michele Mottini (Sep 22 2021 at 17:53):
Working with Anthem a requirement came up to make available the amounts a member paid against a claim (and a claim item) from their HSA account
Michele Mottini (Sep 22 2021 at 17:55):
That to the best of my understanding is not currently covered in https://hl7.org/fhir/us/carin-bb/stu1.1/ValueSet-C4BBAdjudication.html - so we used a custom code
Michele Mottini (Sep 22 2021 at 17:55):
Worth considering adding it to the specs? Cannot find any existing issue about HSA - happy to add one
Corey Spears (Sep 22 2021 at 19:23):
That is not included in the guide today. Can you please enter a ticket for us to consider? Are there other types of payer aware/managed accounts that should be considered, like FSA, others?
Daniel Venton (Sep 22 2021 at 19:41):
How does Paid from an HSA account differ from Paid by Patient? How would a payer know that the member paid their portion of the bill via HSA, cash, check or CC?
Michele Mottini (Sep 22 2021 at 21:15):
How would a payer know that the member paid their portion of the bill via HSA, cash, check or CC
I am not sure, but apparently Anthem does: it has two separate fields for paid by patient and paid from HSA
Michele Mottini (Sep 22 2021 at 21:22):
Created https://jira.hl7.org/browse/FHIR-33996
Paul Church (Sep 22 2021 at 21:24):
Maybe they know if it came from an HSA because of the reporting needed to make sure HSA money only goes to valid destinations? I'm not up to speed on how that stuff works.
Michele Mottini (Sep 22 2021 at 21:36):
_they know everything_
Kate Dech (Oct 13 2021 at 23:16):
Following this thread/JIRA. We are a PBM Payer and also have an ask to represent the HSA/FSA payment tied to a claim. I'm not sure it's adjudication payment type - as a payer we aren't making the payment. The savings account administrator makes the payment It's more like a related Payment based on/referencing this claim from an HSA account to a provider or a member. They want to be able to view that in the context of the claim that triggered the payment.
@Mona O
Kate Dech (Oct 27 2021 at 17:49):
@Michele Mottini - Something occurred to me re-reading your note. The adjudication amount type slice in C4BB has a required binding to that value set - http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication. If Anthem created their own code, would that make them out of conformance with C4BB (and did they do it anyway to be able to send the data they felt was needed)? Thanks!
Michele Mottini (Oct 27 2021 at 18:06):
Good point, I though that the slice was open, but it is actually closed (why?!), so adding that code (that we did) does break conformance
Michele Mottini (Oct 27 2021 at 18:07):
(hard to believe that it would really matter for clients ?)
Corey Spears (Oct 27 2021 at 19:40):
Yup, looks closed with a required binding on the discriminator property. I am not sure why that was done as it predates my direct involvement. This is the time to re-evaluate. I will raise this with CARIN and the FM WG.
If this was made open, would it b sufficient to address https://jira.hl7.org/browse/FHIR-33996?
Kate Dech (Oct 28 2021 at 14:30):
If that was open, it would certainly help. Although it would be nice to have consistent codes for this type of a payment or reimbursement. (Are there separate codes for HRA or HSA or FSA or just one code for member reimbursement by account?)
Corey Spears (Oct 28 2021 at 17:05):
To be honest, we have been hard pressed to find someone to talk to us about the need. It was not clear that this information would even be available to many data suppliers. Who might be able to talk to us about the requirements?
Kate Dech (Oct 28 2021 at 18:24):
It may make sense to get a couple of payer representatives to talk about different types of adjustments.
We have one category of 'member payment reductions' -
FSA = Flexible Savings Account
HRA = Health Reimbursement Arrangement
HSA = Health Savings Account
MIX = Combined Savings Account
MRA = Member Rebate Account
MSA = Member Savings Account
VBA = Voluntary Emp Bnfcry Assn
ALT = Alternate Patient Pay
But there are other adjustments which may reduce the member responsibility (like LICS for MCARE), Coverage Gap Discounts, and also penalties which may increase the member responsibility.
Kate Dech (Oct 28 2021 at 21:20):
Sorry one more thing... It looks like EOB.total has an extensible binding to C4BB Total Category Discriminator (extensible) so it may be possible to add these codes to the total. It's item.adjudication where it's a required binding. I doubt that HSA/FSA/HRA tie payments to a line items.
Michele Mottini (Oct 28 2021 at 21:50):
This come from Anthem, not me directly. I asked someone there to chime in
Michele Mottini (Oct 28 2021 at 21:50):
(and yes, making it open would definitely help - and I think it is a good idea in general for all the slicing, not much sense in preventing servers to add more slices with their own stuff)
Shamil Nizamov (Nov 01 2021 at 17:05):
FSA = Flexible Savings Account
HRA = Health Reimbursement Arrangement
HSA = Health Savings Account
MIX = Combined Savings Account
MRA = Member Rebate Account
MSA = Member Savings Account
VBA = Voluntary Emp Bnfcry Assn
ALT = Alternate Patient Pay
What would be the CodeSystem for these account types?
MaryKay McDaniel (Nov 01 2021 at 19:48):
Hi FM Co-Chairs here:
to indicate an HSA Payment:
There would need to be a Coverage resource for the HSA.
EOB.insurance.coverage = HSA Policy
EOB.item.adjudication.category = 'benefit'
EOB.item.adjudication.amount.value = the amount paid/payable from the HSA Policy
Feel free to join the FM Calls on Tuesday mornings if you have additional questions.
THANKS!!
Daniel Venton (Nov 01 2021 at 20:40):
Assuming that there are 3 payers on a claim. 2 (HSA + HDHP) insurance and 1 "cash".
Thus the 1st payer is HDHP, that eob will reference the focal coverage resource HDHP plan.
The second payer is HSA, that eob will reference the focal coverage resource HSA plan, plus a reference to the prior payer (HDHP).
Correct?
Michele Mottini (Nov 01 2021 at 21:30):
I don't get it, EOB.item.adjudication.category = 'benefit' is an existing code, how do you know that it is a payment from an HSA?
Daniel Venton (Nov 02 2021 at 12:11):
EOB1. "benefit" was paid by referenced coverage (an HDHP plan)
EOB2. "benefit" was paid by referenced coverage (an HSA plan)
Michele Mottini (Nov 02 2021 at 12:32):
So you have to have two different ExplanationOfBenefits? Don't think that's what is wanted
Michele Mottini (Nov 02 2021 at 12:32):
So if you have an HSA payment you need two ExplanationOfBenefits?
Daniel Venton (Nov 02 2021 at 12:42):
I think it comes down to what is HSA? Is HSA a form of currency like cash or credit card or is it insurance?
If it's insurance, then it has a coverage and an EOB is a record of payment/adjudication by 1 insurance plan.
If it's currency, then it's just "paid by patient" and be done with it.
It sounds like it is treated as insurance, thus it is treated like an insurance plan. When you have 2 insurance plans you get two EOB.
This is just me stitching various comments together, I'm a technologist not an insurer.
John Moehrke (Nov 02 2021 at 13:32):
My understanding - To the patient it is very different, as it is non-taxed-money, and thus the patient has obligations to track for tax purposes. But to the healthcare org and insurance, it is just "paid by the patient", simply cash to them.
Paul Knapp (Nov 02 2021 at 17:05):
@Daniel Venton an HSA is a pre-tax spending account which acts like 'cash' for settling patient responsibility on health services.
Paul Knapp (Nov 02 2021 at 17:09):
@Michele Mottini Yes you may have multiple EOBs, if a claiming mechanism was used (although on the FM call none of the providers or payers had that use case) then you may have multiple EOBs as the HSA may not be managed by the payer.
Daniel Venton (Nov 02 2021 at 17:20):
Michele Mottini said:
Working with Anthem a requirement came up to make available the amounts a member paid against a claim (and a claim item) from their HSA account
I understand what an HSA is. The question arose how to know if an HSA paid for a bill vs paying cash vs insurance. If "paid by patient" means paid by patient using any currency type (cash, HSA) then there is no way to differentiate between the types.
There seem to be 2 possible solutions, add more adjudication categories to say, "paidbypatientcash", "paidbypatientHSA", "paidbypatientetc".... but there isn't anything on the claim form to indicate patient swiped HSA card vs patient swiped debit vs credit vs cash.
OR
treat HSA as an insurance in which case it becomes Coverage and the adjudication category of "benefit" would be used to indicate amount paid by the insurance (HSA). Also problematic unless HSA account acts like insurance, which I don't think does.
I think the correct answer is: There is no current way to tell whether the "paidbypatient" amount was by cash, HSA or other. Unless you are in the Provider's practice where you can see the assorted transactions against the patient account. But it won't be on the EOB.
Pat Taylor (Nov 10 2021 at 12:50):
However, I understand that some payers do know if the "paidbypatient" amount was cash, HSA or other. A recommendation is to add "paidbypatientcash" and "paidbypatientHSAHRAorother" to the adjudication value set and let payers determine which value best works for them.
Last updated: Apr 12 2022 at 19:14 UTC
