Healthcare Accumulators Solution with Blockchain


In the healthcare payer space, deductibles and out-of-pocket maximums must be processed carefully. Managed as accumulators, both medical and pharmacy claims processing systems need to be in sync to provide accurate amounts from pharmaceuticals, to payers, to pharmacy benefit managers (PBMs), to the patient. But with current technology, systems not run in real time could be out of synchronization for as long as 24 hours, risking inaccurate charges and increasing patient frustration.

Blockchain-based Healthcare Accumulators Solution creates a single, unified interface that boosts business efficiency within the organization and is even enabled across organizations. With the power of blockchain, this solution increases customer satisfaction while opening doors to new partnership opportunities in a trusted environment.

Managing and Accumulating Healthcare Claims Data Across Systems

Every year, millions of individuals across the United States make planned (and sometimes unplanned) visits to their primary care physician, or urgent care, or a specialist to treat their medical conditions, using health insurance to help cover the costs of treatments and medicines. Many or most of these visits will entail some consumer payment, since most health insurance subscribers must pay an out-of-pocket maximum before insurance benefits entirely take effect.

This, in turn, requires accurate tracking and reporting of deductibles and out-of-pocket payments—known in the healthcare industry as “accumulators”—for all parties, including patients, providers, and payers. It’s especially important for consumers, who often contact healthcare providers to challenge or better understand charges they’ve been billed for. This is especially the case when they thought they had reached an out-of-pocket maximum or deductible.

A major healthcare organization in the United States faced an enormous challenge in providing a standard view of accumulators across both medical and pharmacy claims processing systems. Data synchronization was at least 24-hours out of sync among various systems, meaning that at times an individual’s deductible or out-of-pocket limit may have been met but not recognized in real time. This led to inaccurate charges and time-consuming reconciliation work.

The organization turned to the experts at Luxoft, an AWS Partner Network (APN) Advanced Consulting Partner and AWS IoT Competency Partner, to understand how it may be able to use blockchain technology to solve a decades-old data reconciliation problem and drive better outcomes for all parties involved. As a global IT service provider and consulting firm, Luxoft helps companies in highly regulated industries meet business challenges and drive innovation using advanced technologies.

Mapping Healthcare Business Needs to Blockchain Technology

The healthcare provider uses many different systems to process various medical and pharmacy claims. Each system is separately controlled by various payers, medical benefits and pharmacy benefit. After spending time with the organization to understand its business model and pain points, Luxoft identified the potential for blockchain, a distributed ledger that cryptographically links and secures records to one another via timestamps and other attributes, to unify the disparate systems managed within the healthcare organization.

“The payers systems aren’t unified,” says Todd Gehrke, blockchain solutions architect at Luxoft. “Claims are processed and billing is calculated using accumulator values that are synchronized using batch processes. We devised a method for the payer’s legacy systems to tie into a blockchain to share accumulator totals. We were targeting a use case that provided significant value with minimal disruption.”

By connecting systems in near real time using a private blockchain, Luxoft determined that the organization could share and update real-time accumulators in a secure, reliable, and auditable way.

Benefits & Outcomes

Working with a Third Party Administrator (TPA) and a Pharmacy Benefits Manager (PBM), the Blockchain solution will provide accurate real-time updating of an Insured Member’s Accumulator Account.

Prime Direct Benefits

  • All parties have access to the same, accurate, synchronized and validated data
  • Less paperwork and manual reconciliation, lower or no reconciliation events
  • Lower or no cost for reconciliation events
  • Improved customer experience – Higher Net Promoter Score (NPS)

Prime Direct Benefits

  • No disruption to medication adherence
  • Real-time data for Plan Sponsors
  • Better Payment Liability Estimation (PLE) for Insured Members
  • Marketing value for the TPA as recognized pioneer
  • Readily extendable to other EHB services
Further Info

In the healthcare payer space, deductibles and out-of-pocket maximums require strict attention to detail for each individual member. Managed as accumulators, both medical and partnership claims processing systems need to be insync with real-time information to provide accurate amounts across the healthcare ecosystem.

Recently, a major healthcare organization in the United States came to us with systems lacking real-time information updates for as long as 24 hours, risking inaccurate charges. Reconciling the two systems was a very tedious and time consuming task, and customer satisfaction was suffering as a result.

However, by leveraging Appian’s ability to integrate with countless systems, Luxoft was able to offer a secure, reliable, and auditable way for medical and partnership systems to share and update real-time accumulators. Implemented via Hyperledger Fabric, the accumulator blockchain solution uses channels to isolate and secure data across medical and benefit partnerships.

Integrating blockchain with Appian creates a single, unified interface that boosts business efficiency within the organization while being readily accessible across organizations. With the power of blockchain, this solution can increase customer satisfaction while enabling new partnership opportunities in a trusted environment. Further, this solution is a step toward moving enrollment, claims adjudication, and payment logic into smart contracts, which can eliminate the need for benefits administration.

There is massive potential for blockchain solutions. These solutions will drive a fundamental shift in how different entities and the healthcare industry connect — enabling better outcomes for individuals.

But in order for the healthcare industry to benefit from blockchain, key players in the space need to participate in specific blockchain-based use cases. They need to take part in a deductible or supply chain blockchain by uploading information to the network, which will help attract more participants and increase the value of the data-rich network. Only then will other companies in the healthcare space follow, after seeing how those in the network reap invaluable benefits.

To accomplish blockchain’s full potential, open systems and standards are critical. It is important that everyone involved in a blockchain consortium works together to decide on how to operate. Ideal consortiums are comprised of existing partnerships as well as former competitors, revealing a unique ecosystem that is not possible anywhere else.


This project is Live

© Antony Welfare 2024