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.
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.
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.