In our last blog we discussed potential use cases for blockchain in B2B, B2C and government services, focusing on how blockchain can make business processes more agile, secure and cost efficient. In this blog we’ll focus on healthcare specifically as blockchain could have an even more transformative impact in healthcare than the financial services industry. The healthcare landscape is currently defined by fragmented systems and limited data visibility across different stakeholders — resulting in massive inefficiencies. By enabling multiple parties to share data and perform automated inter-organization processes in a distributed, transparent and immutable fashion, blockchain technology has unique advantages that make it ideal for applications in healthcare.

Blockchain for healthcare claim processing

Enabling a Single, Accurate Source of Provider Data

Providers are a part of one or more payer networks. A member registered with a payer can receive services from any provider that is a part of the payer network. That sounds straightforward enough, but what happens when things change — say, a provider relocates, changes hours of operation or moves into or out of the payer’s network? Any of these changes would need to be accurately logged into the payer network so that members receive accurate information and don’t avail the services of providers outside of the network. Today, like the know your customer (KYC) process carried out by banks, payers reach out to providers annually to verify their information. This is pure cost to the payer. Worse, whenever information changes, multiple siloed systems must be updated with the same data — and if a provider is a part of multiple payer networks, then this same exercise must be performed by all payers. Until provider data has been accurately updated, all related claim processing must be done manually — adding to costs and increasing overall cycle time. This is part of the reason why something like 40% of payer’s provider data contains errors or missing information.

In contrast, imagine that a blockchain network could be created with payers, providers and members as stakeholders and all siloed systems unified through the network. Since all the provider data would be stored on this network, any update to the provider data would only have to be done once — and the update would propagate to all the systems of all the payers. Such a network could also save members from seeking services from providers that are not part of the network.

Dispute-Free Claims Adjudication Process

Claims adjudication — the process in which a payer receives a member’s medical bills, and claims are accepted or rejected based on the member’s policy — is ripe for blockchain innovation. Currently, this process is manual, and many disputes arise from rejected claims. But blockchain could facilitate the entire process using “smart contracts” — programs that reside on the blockchain network and allow for automation across organizations. Insurance policies would be captured in these smart contracts, and therefore visible to and agreed upon by all stakeholders. In addition, bills generated could be automatically verified against policies by smart contracts, reducing the overall cycle time while lowering costs and eliminating disputes.

Blockchain for Fraud Prevention

In 2014, the federal government recovered $5.7B in healthcare fraud cases. While these cases stem from a range of different sources, from incorrect billing to corruption and false claims, what they have in common is that they were made possible by the opaqueness of data across organizations. Getting prescriptions, bills of medicines and medical treatment onto a blockchain network — and making all this information visible to members, payers, providers and pharmacies — would significantly curtail the scope of healthcare fraud. Here, the immutability of the blockchain network presents an important advantage, because it would be impossible to tamper with data already present on the network.

Blockchain could also be used to better protect members’ sensitive healthcare data by creating a system in which members grant permission to individuals or organizations to access their data. No system like this currently exists, in part because, before blockchain, the idea that data could be securely co-owned by multiple parties who did not trust each other was inconceivable. It bears pointing out that healthcare is more prone to data breaches than other industries, and a 2015 study found that roughly 90% of the most significant healthcare data breaches had centralized authentication mechanisms as their root cause. But blockchain networks, because they incorporate a distributed authentication mechanism and do not have a single point of failure, are safeguarded against such attacks.

Of course, these examples are just scratching the surface. Secure, predictive models could be applied to members’ medical data to support proactive treatments with reduced costs and higher quality service. Analytics — for instance, to enable dynamic premium prices depending on member records — could also be incorporated. And extending blockchain to drug supply chains will help detect fake drugs earlier and prevent them from entering into circulation; prescription drugs could also be more precisely tracked and monitored this way. The possibilities are immense — and all of them point to faster processes, lowered costs, safer products and improved experiences for members. A win-win situation for all!

The Blockchain Adoption Curve in Healthcare

Clearly there are many areas where blockchain can improve healthcare processes, so where will the industry begin taking advantage of the benefits of blockchain? The following is a potential adoption curve followed by some middle ground areas.

Early adoption areas (areas where payers are required to fully disclose details to the public)

  • Provider network details: Provider directories must be printed out and maintained accurately, which poses major problems, particularly in Medicare Advantage (MA) plans — as evidenced by the massive fines that have been levied against several MA plans in recent years.
  • Benefits/coverage: Each payer must make thousands of permutations of policies and benefit structures publicly available for providers and members to navigate. Ongoing changes, which sometimes occur mid-year, further complicate matters.
  • Medical policy: Medical policy, which often varies with geography and local regulations, must be publicly available — a significant challenge for most plans currently.
  • Authorizations: At the intersection of benefits and medical policy, authorizations are perhaps the single-largest source of confusion for members/providers, resulting in denied claims, late payments, appeals and grievances. Payers need to be clear on how medical policy applies to benefits to cover specific treatments.

Late adoption areas

  • Provider reimbursements/payments and related information: While this area is ripe for innovation, the reluctance of payers to share details related to provider contracts makes early adoption of a blockchain solution unlikely.
  • Protected Health information (PHI) and Personally identifiable information (PII): The number of different stakeholders involved, combined with potential risks, make this another late adoption area.

Middle ground

  • Claims clearinghouses: A blockchain solution would address issues related to the status and disposition of claims.
  • Provider scheduling: A blockchain solution fo