Accelerating Government Benefits Determination through TEFCA: Paving the Way for a Better Tomorrow

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September 17,2025

Automated System Poised to Cut Social Security disability Claim Wait Times

Washington D.C. – individuals applying for Social Security disability Insurance (SSDI) may soon experience a dramatically faster process, thanks to a nationwide effort to streamline medical record access. The Social Security Administration (SSA) currently faces notable delays, with initial claims taking, on average, more than 200 days to process. A major contributor to this backlog is the time-consuming effort to obtain necessary medical documentation from healthcare providers.

The Cost of Delays

The current system is not only frustrating for applicants but also financially burdensome. The SSA estimates it spends over $500 million annually collecting and verifying medical evidence. This expense ultimately falls on taxpayers and underscores the urgent need for a more efficient solution. According to data released by the Centers for Medicare & Medicaid Services, administrative simplification initiatives saved the healthcare industry an estimated $18.4 billion in 2023 alone, demonstrating the broad economic benefits of improved data exchange.

TEFCA: A New Approach to Record Access

The trusted Exchange Framework and Common Agreement™ (TEFCA™) offers a promising path forward. This initiative seeks to automate the medical records request process, enabling the SSA and other government agencies to quickly and securely access the facts needed to adjudicate claims. Early data suggests that applications with readily available health IT records are approved nearly 60 percent faster.

How it Works: Directed Queries and FHIR

A key component of this betterment is the updating of the Qualified Health Information Network® (QHIN™) technical Framework. These updates will facilitate “directed queries,” which allow for precise requests for medical records to be routed efficiently across different networks. Ten designated QHINs are preparing to implement these changes. The updates also support the use of Health Level Seven® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) Application Programming Interfaces (APIs), a modern standard for healthcare data exchange.

Did You Know? FHIR APIs are becoming increasingly prevalent in healthcare, offering a standardized way for different systems to communicate and share information.

Benefits for Patients and Providers

The anticipated benefits are twofold. For individuals, it means quicker access to disability coverage, alleviating financial hardship and uncertainty. For healthcare providers, it translates to less administrative burden and reduced uncompensated care. Pro Tip: Healthcare providers should familiarize themselves with TEFCA and FHIR to prepare for the evolving landscape of health information exchange.

Current Process	TEFCA-Enabled Process
Manual medical record requests	Automated, directed queries
Average claim processing time: 200+ days	potential reduction in processing time by 60%
high administrative costs for SSA	Reduced costs through automation

The TEFCA Recognized Coordinating Entity^® (RCE^®) is currently finalizing implementation specifications in the Government Benefits Determination Standard Operating Procedure, paving the way for widespread adoption.

The Broader Impact of Interoperability

The TEFCA initiative is part of a broader movement towards greater healthcare interoperability. Improved data exchange between healthcare providers, insurers, and government agencies is crucial for enhancing patient care, reducing costs, and promoting innovation. The 21st Century Cures Act, passed in 2016, has been a driving force behind these efforts, mandating the adoption of standardized data exchange protocols.

Frequently Asked Questions

• What is TEFCA? TEFCA is a framework designed to automate the exchange of medical records for various purposes, including government benefits determination.
• How will TEFCA affect Social Security disability claims? It is expected to significantly reduce claim processing times by streamlining the medical record request process.
• What are FHIR APIs? FHIR APIs are a modern standard for exchanging healthcare information electronically.
• What are QHINs? Qualified Health Information Networks are organizations designated to participate in TEFCA and facilitate data exchange.
• How much money does the SSA spend on collecting medical evidence? The SSA spends over $500 million annually on this task.
• Will TEFCA benefit healthcare providers? Yes, it will reduce their administrative burden and potentially decrease uncompensated care.
• Is TEFCA mandatory for healthcare providers? participation will likely evolve over time, but the trend is toward greater interoperability requirements.

What are your thoughts on the potential for TEFCA to improve government services? How do you envision healthcare interoperability evolving in the next five years?

share your opinions and join the discussion in the comments below!

How can TEFCA’s standardized data formats and vocabularies specifically reduce inconsistencies in benefits eligibility criteria across different states and programs?

Understanding the current Challenges in Benefits Eligibility

Determining eligibility for government benefits – including Medicaid, SNAP (Supplemental Nutrition Assistance Program), and housing assistance – is often a slow, fragmented, and frustrating process for both applicants and administering agencies. Several key factors contribute to these inefficiencies:

* Data Silos: Information relevant to eligibility resides in disparate systems across various state and federal agencies. This lack of interoperability necessitates manual data collection and verification.

* Manual Processes: Reliance on paper-based applications,faxed documentation,and manual data entry leads to errors,delays,and increased administrative costs.

* Verification Bottlenecks: Verifying applicant information (income,residency,identity) with third-party sources can be time-consuming and complex.

* Inconsistent Standards: Varying eligibility criteria and documentation requirements across different programs and states create confusion and administrative burden.

* Increased Demand: Growing populations and economic fluctuations often lead to surges in benefit applications, overwhelming existing systems.

These challenges result in delayed benefit access for those in need, increased administrative overhead for government agencies, and potential for errors and fraud. Modernizing this system is crucial for equitable access and efficient resource allocation.

TEFCA and the Promise of Nationwide Health Information Exchange

The Trusted Exchange Framework and Common Agreement (TEFCA) represents a landmark step towards addressing these challenges. Developed by the Office of the National coordinator for health Information Technology (ONC), TEFCA establishes a common set of principles and technical standards for enabling nationwide health information exchange (HIE). While initially focused on healthcare, its principles and infrastructure are directly applicable to streamlining government benefits determination.

How TEFCA Works: A Simplified Overview

TEFCA doesn’t create a single national database. Rather,it establishes a network of “Qualified Health Information Exchanges” (QHINs). These QHINs are organizations that meet specific technical and operational requirements and agree to adhere to the TEFCA framework.

Here’s how it functions:

1. Data Exchange Agreements: QHINs enter into agreements with each other, defining the terms and conditions for exchanging information.
2. Common Data Standards: TEFCA promotes the use of standardized data formats and vocabularies, ensuring that information can be understood and utilized across different systems.
3. Privacy and Security: Robust privacy and security safeguards are built into the TEFCA framework,protecting sensitive applicant data.
4. Consent Management: TEFCA supports mechanisms for individuals to control access to their information.

Applying TEFCA Principles to Government Benefits

The core principles of TEFCA – interoperability,standardization,security,and consent – can be leveraged to revolutionize government benefits determination. Here’s how:

* Expanding QHIN Participation: Encourage QHINs to extend their services to include government agencies responsible for benefits administration.

* Developing Benefits-Specific Data Exchange Agreements: Create agreements tailored to the specific data elements required for benefits eligibility verification (e.g.,income,employment,residency).

* Standardizing Benefits Data: Adopt common data standards for key eligibility criteria,facilitating seamless data exchange between agencies and third-party sources. This includes leveraging existing standards like HL7 FHIR where applicable.

* Secure Data Sharing: Utilize TEFCA’s security framework to ensure the confidentiality and integrity of applicant data during exchange.

* Applicant-Controlled Consent: Empower applicants to authorize the release of their information to benefits agencies, promoting transparency and trust.

Specific Use Cases for TEFCA in Benefits Determination

Let’s explore concrete examples of how TEFCA can accelerate benefits eligibility:

* Income Verification: Automatically verify applicant income with employers or payroll providers through secure data exchange, eliminating the need for pay stubs or tax returns.

* Employment Verification: Confirm employment status directly with employers, streamlining the verification process for unemployment benefits or job training programs.

* Residency Verification: access verified residency information from state motor vehicle departments or utility companies, reducing the risk of fraud and ensuring accurate eligibility determination.

* Medicaid Eligibility: Streamline the Medicaid enrollment process by securely exchanging eligibility information between state Medicaid agencies and healthcare providers.

* SNAP Eligibility: Verify household income and resources with financial institutions, improving the accuracy and efficiency of SNAP benefits distribution.

Benefits of TEFCA Implementation for Government benefits

Implementing TEFCA-aligned solutions offers a multitude of benefits:

* Reduced Processing Times: Automated data verification and streamlined workflows significantly reduce the time it takes to determine benefits eligibility.

* Lower Administrative Costs: Reduced manual effort and fewer errors translate into substantial cost savings for government agencies.

* Improved Accuracy: Automated data exchange minimizes the risk of human error and fraud, ensuring more accurate benefits distribution.

* Enhanced Applicant Experience: Faster processing times and reduced paperwork create a more positive experience for benefit applicants.

* Increased Equity: Streamlined access to benefits helps ensure that those in need receive timely assistance.

* Better Data Analytics: Consolidated data from multiple sources enables more comprehensive data analytics, informing policy decisions and program improvements.

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