Hospitals and health systems today increasingly seek to improve revenue cycle management performance by reducing denials and boosting patient collections.
Blockchain technology, a permanent shared record of online transactions or exchanges, can help with these goals because it allows payers, providers and financial institutions to share information via private distributed ledgers. When this happens, it prospectively helps providers reduce claims denials and secure patient payments, says Lynn Carroll, chief of healthcare strategy and operations at HSBlox, an Atlanta-based provider of healthcare finance and IT solutions. It also helps payers to price and adjudicate claims, and release reimbursement in real time, immediately generating explanation of benefits for patients.
"Healthcare RCM today is primarily focused on correcting issues after they occur," he says. "Providers dedicate an inordinate amount of time, money and personnel appealing denials and often are at risk of patients not paying their portion of the bill, especially in these days of high-deductible health plans. Payers also expend a tremendous amount of resources processing claims that should be automatic. By using blockchain and machine learning, we are taking a prospective approach that helps providers and payer[s] avoid these issues, which will improve the entire revenue cycle for all — including patients/members."
Here, Mr. Carroll provides four ways to improve RCM with blockchain.
1. Value-based contracting initiatives. Healthcare organizations using value-based contracting initiatives can benefit from automation using smart contracts to administer bundled payments and episodic reimbursement models on blockchain, according to Mr. Carroll. He gave the specific examples of integrated delivery networks, hospitals or ASCs bearing risk for a total hip replacement. In those examples, all parties are involved in value-based contracting initiatives and must report/disclose quality data regarding care guidelines. "There will be an ultimate risk bearer, [and] there will be some post-acute service providers that may also be included in that bundle," says Mr. Carroll. "These folks are all under different trust boundaries meaning they have providence over their own data and have come together and contracted under a value-based reimbursement program like a bundle." By using smart contracts on distributed ledger technology, he says they can report their data at a granular level and as necessary on a permissioned basis among parties during the episodic event. That information then helps determine the reimbursement and how much money the parties will have to collect from the patient.
2. Real-time claims settlement and adjudication. Smart contracts on blockchain also allow for real-time claims administration and settlement processes, as well as EOB statements, at the point of service, according to Mr. Carroll. He says claims are quickly validated using machine learning across historical claims and remittance data, and claims administration, using smart contracts on distributed ledger technology, allows hospitals and health systems to settle claims in real time and generate EOBs for health plan members at the point of service. This could particularly be helpful during discharge. Mr. Carroll says the claim could be submitted at discharge, "bounce" against the smart contract with the payer, and the claim could be priced and settled in real time. He noted this creates improved efficiency for payers and faster reimbursement for providers.
3. Point-of-service transparency for patients. For patients, real-time EOBs — generated at the point of service using smart contracts — provide transparency with respect to their financial responsibility. Mr. Carroll equated this to a consumer buying merchandise at a retail store. In that instance, he says, the receipt is the explanation of the purchase, but funds haven't moved until a settlement process occurs through banks. With the patient, they receive an EOB detailing patient responsibility and financing opportunities, validated by a rule set on the distributed ledger technology that include the payer, provider and financial institution, says Mr. Carroll. "So financing opportunities are granted or made available to the patient after input from the provider, payer and financial institution. So all [of those parties are] receiving real-time notifications on a blockchain-based solution for patient financing." He says providers also benefit from this because patients who know their financial responsibility and financing options may be more likely to pay or arrange for payment at the point of service.
4. Tailored patient financial programs. Through real-time claims validation and patient payment scoring indicating the patient's ability to pay, hospitals and health systems are able to partner with financial institutions in offering tailor made financial programs for patients, according to Mr. Carroll. One challenge for hospitals, however, is the reliance on workers at admitting and discharge to discuss financial programs with patients. But patients who do learn about their financial options enjoy the consumer-centric aspect, says Mr. Carroll. This is particularly true as patients take on more financial responsibility for their care due to the rise in popularity of high-deductible health plans. Providers are also likely to receive proper reimbursement in a timely manner.
~~~~~~~~~~Article written by Kelly Gooch, published in Becker's Hospital Review; Jessica Kim Cohen contributed to this report.