Okay, before you presume that I am going to run you through the same cliché “What is blockchain blah blah” drivel, let me assure you that that’s not the case at all! Obviously if you still need a refresher on what blockchain is, let me gladly point you to this little slideshow  that I have prepared as a ready reckoner on blockchain; shouldn’t take more than 6.5 minutes to read through the deck.

In case you are totally aware what blockchain is, and why is it making waves in IT World, let’s explore a very specific Line of Business under Healthcare Industry. [ A one-line “Know it All” Wisdom on Healthcare Nomenclature for you: If you break your leg and go to a hospital, and your healthcare Insurance company pays for the treatment and/ or surgery to the hospital, then You = Member; Your Insurance Company = Payer; The hospital = Provider. Easy?]

Now, in many countries, there is deep collaboration among the insurance payers to ensure seamless service for their customers – the members – even if they are out of their home network. The moment you are out of your home network, you will be, in accordance to the agreement among the payer companies, entitled to Healthcare insurance services through the partner networks. Let’s take an example:

Imagine you are registered as a member with Stark Insurance (excuse my obsessions with Graphic Novels). In other words, you have bought a Healthcare Insurance policy that covers you against your Healthcare expenses in exchange of a premium amount. Imagine you are a resident of the State of West Virginia (John Denver, anyone?) and you travel to North Carolina. Now, while in NC, while taking a leisurely bike ride, you fell off and fractured your leg. you had to be admitted to a hospital at NC. Consider the situation: Your Healthcare Insurance provider only provides service in your home state, WV, while your host state NC is where you need your services.

There is a special program in the US called Bluecards. This program is only applicable for helathcare insurance companies empaneled under Blue Cross Blue Shield Association. BlueCard is a US national program that enables members of one Health Plan with a certain provider to obtain healthcare services while traveling or living in another Provider’s service area. The program links participating healthcare providers with the independent Blue Cross and Blue Shield Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement. This network is, as of today, a collection of individual collaborations between the respective insurance providers.

So far so good? Well, not really, you know. the network we talked about works in two levels. a commonly run back end system of records and individual ledger systems with each of the payers.Common sense says that maintaining such a huge network is no child play. Imagine a member of company A moving from home state to host state serviced by empaneled payer B. In case of a service request at B, the payer B would have to

  1. Request the details of the member from original payer.
  2. Once obtained, check if services need prior authorization.
  3. Send the request back to A
  4. Wait for prior authorization response
  5. Reconcile the expenses and check for remaining covers (more to and fro data exchange).
  6. Process Claims
  7. Send back the updates to A

Also, everyone has to update two version of ledgers.

  1. The global System of Records
  2. Their local ledgering system

Now comes the fun part.

Imagine a world where every major insurance players are connected, and are members of a simple blockchain network. You as a customer travel to any Geography and need healthcare service. The blockchain would hold certain verification information and the current coverage remaining, coverage terms, Insurance provider etc. Say you have about 5000$ remaining in your insurance cover. The payer that would be servicing you in the new geography would simply query the blockchain, process the claim, and update the blockchain again with the transaction details. Even simple prior authorization business rules can be persisted in blockchain itself using “smart contracts” (using rapidly evolving blockchain based programming languages like Solidity etc.) .The approval for treatment or surgery thus happens instantaneously. Reconciliation between the payers can happen later. Just imagine how drastically it would bring down the delay since the entire latency time owing to to and fro communication between the home and host payers is virtually eliminated. The patient gets the service exactly when he/ she needs it the most. Turnaround time gets reduced and thus Customer Satisfaction would increase.

Do you think this might be a viable solution in the near future which can transform Claims processing in Healthcare Domain? What other use cases can you think of? Join the conversation by connecting with me via LinkedIn, my website https://ITLatte.com or my Facebook page https://www.facebook.com/YourITLatte/

Happy Learning! 🙂