Blockchain Use Case: Financials, Insurance & Records

With early distributed ledger technology (DLT) successes seen in the financial technology (FinTech) arena, the escalating cost of healthcare, and the continuing challenges around fraud (particularly from a federal perspective), healthcare finance has some of the most well-aligned needs for the characteristics of blockchain [1].

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Payment Processing Life Cycle

Organizations are working to replace manual processes and reconciliations for payers and providers with blockchain-facilitated smart contracts, currently, Change Healthcare and TIBCO Software are providing two solutions in this space. Efficiency gains in claims adjusting payment processing and related healthcare transactions will be sought using their Intelligent Healthcare Network and Project Dovetail, respectively. This approach seeks to capitalize on an open-source platform (i.e., Project Dovetail) to encourage developer adoption and builds upon the blockchain base.

Insurance Claim Processes

Claim transaction verification related to healthcare (e.g., preauthorization payment) as well as leveraging the utility of smart contract-enabled DLT and HL7 FHIR® to automate health insurance claim processing has been outlined in the table below.

Table. Blockchain benefits and use cases to enhance the insurance claim process

Kuo et al.J Am Med Inform Assoc 2017; 24(6):1211-1220 via Creative Commons license.

Blockchain Benefit Enhanced Insurance Claim/Fraud Process
Decentralize Management Real-time claim processing: “The ability to remove intermediaries from a process is the capability that sets Blockchain apart from other technologies. This capability will allow the solution to facilitate real-time claims adjudication by replacing the health plan intermediation with transparent Blockchain technologies.”
Immutable Audit Trail Improved claim auditing and fraud detection: “Payer, private and government insurers, and individual payers have the benefits of] audits facilitation and better fraud detection [based on Blockchain immutability].”
Data Provenance Verifiable records for claim qualification: “[The chief obstacle of the claim qualification process] is the distributed nature of the many records that feed the decisions of patients, providers, and Medicaid administrators… The requirements for verification… are precisely the obstacles that a distributed blockchain solution… can address.”
Robustness/Availability Enhanced accessibility of patient data: “[Provider, health-related services and medical goods have the benefits of] patient data accessible from multiple silos [based on Blockchain virtual ledger].”
Security/Privacy Increased security of patient medical insurance information: “[Member/patient have the benefits of] less likelihood of hacking of… financial information [based on Blockchain mechanism].”