Blockchain is one technology which is touching every industry in some shape or form. Most importantly, the use case of blockchain technology comes in areas where trust among different parties and stakeholders needs to be established. Blockchain, a shared distributed ledger technology, eliminates the need for an intermediary to govern a transaction thereby reducing the chances of malpractice and cost burden these intermediaries put in the system.
Initial use cases of blockchain were around financial services where the most deliberated one was around decentralised cryptocurrency. Recently the healthcare industry is showing a lot of promise around blockchain as this whole industry is still running on manual processes and lot of intermediaries in between to complete a transaction like claim settlement.
Between claim submission and claim settlement there are many processes, such as benefits verification, claim adjudication, and actual payment which involves multiple parties like healthcare providers, clearing houses, coders, payers, and bankers. This complete cycle takes days to months because of manual intervention and exchange of fax, report scans, and policy details. In this loop, the duplicity of claim submitted is one of the key areas which consumes a lot of time, because there is no single source of truth which can be checked for patient information and claim submitted.
According to McKinsey out of 2.7 Trillion USD spending on healthcare solutions in the US, 400 Billion USD (14%) gets to spend on claim processing, payments, medical billing, revenue cycle management, and debts. There is also a high level of error rate around 20% among health insurers, according to American Medical Association (AMA), that represents an intolerable level of inefficiency which causes a loss of around 17 Billion USD, each year, in the US.
Seeing the above trends, clearly, there is a need to enhance the existing systems in healthcare, Electronic Medical Records (EMRs) for example, came into the scenario to provide automation and health care process digitization but slowly organizations realised the challenges of reporting and lack of collaboration in EMRs. These systems are designed in siloes with no single protocol being followed by different EMR solution providers.
Since EMRs cannot operate in collaboration across the healthcare network of providers, clearing houses, etc., the duplicity of data and manual errors by insured/insurer is a pain point. Blockchain, with its decentralized nature and consensus mechanism, can prove to be a savior in these scenarios. For example, benefits verification under the claim processing cycle is one step which can be auto-completed using blockchain.
Benefits Verification Process and Blockchain
Benefits verification is a step under the claim management process which checks for the benefit entitlements of a patient with respect to treatment and facility the patient is looking for. This simple verification process between the healthcare providers and payers takes days to get processed because of manual processes, multiple parties, and duplicity of documentation.
To make benefits verification successful on blockchain in healthcare, we need to have decentralized identity and payer network on the blockchain platform.
Identity management is one of the pain points in the claim management cycle because the identity of a patient is spread across various systems like EHRs, medical charts, prescriptions, clinical documentation solutions, and revenue management platforms. This information is stored in different formats and sometimes are stored in a pictorial format which is not easily shareable. This information using machine learning (ML) can be digitized, and then blockchain can be used to disseminate the relevant patient data to all the different parties, like healthcare providers, payers, clearing houses, etc., by connecting their existing systems with blockchain platform using APIs.
Another aspect is having a payer network as part of blockchain technology. Putting all the payers in a single blockchain platform where every payer sees the verified patient ID and the claim submitted should be the achieved, once it is in place, the smart contract on the blockchain will execute the transaction by matching the patient details in the payer database, and on the real-time basis, can provide the benefit entitlement of patient to the healthcare provider. Once the claim has been submitted it can be tracked on the blockchain to reduce time and cost of reconciliation.
This whole blockchain benefits verification process will prevent duplicate claim submission from the same patient because an entry has already been made in the shared ledger in the payer’s blockchain network. This will also prevent errors in the claim settlement process because identity is managed by blockchain and correct information in unified format gets disseminated to various parties involved.
To make blockchain system work, identity management is one key aspect which needs to be robust. Efforts are being made in the industry by various consortiums like Hashed health, Embleema’s blockchain health consortium and various other startups in this direction and it is of prime importance that a single platform or consortium takes precedence in managing identity solutions by developing AI and machine learning solutions to extract the information out of various healthcare platforms.
Payer network should also be under a single platform and there are various blockchain start-ups working in this direction to bring healthcare providers and payers under the same roof. Healthcare industry giants, including GE, Adventist Healthcare, Change Healthcare, McKesson ventures, and many others are investing in these upcoming start-ups.
Clearly, the healthcare industry is moving towards automation which was long due considering other industries, like financial services and aviation which are already ahead in the curve and embracing blockchain for various use cases. But the future is bright and with the advent of blockchain in healthcare, things will surely move toward better healthcare solutions.