4th September 20195 Minutes

Blockchain-based Smart Contract will revolutionise the billing and payment process and will result in the complete disintermediation of a vast administrative layer within the healthcare Provider and Payer (private insurer or public commissioner) organisation.

Both Providers and Payers will see a huge benefit through a more streamlined process of handling claims and processing payments. The process will also include various steps like checking patient insurance eligibility and coding claims.

Illustrative smart billing and payment process

The example shown below is based on an insured patient, but the process would be similar for the public sector.

1. Upfront
  • Insurer and Provider enter into a Smart Contract on Ethereum blockchain
  • The smart contract would be self-executing with the terms of the agreement directly written into code
  • The smart contract would exist on a distributed and decentralised blockchain network
  • Smart contract would permit trusted transactions and agreements to be carried out between Insurer and Provider without the need for manual intervention (Provider and Insurer), central authority, legal system, or external enforcement mechanism
  • Each transaction would be completely traceable, transparent, and irreversible
  • Automated invoice and subsequent payment would be triggered (i.e. self-billing) inline with pre-agreed protocols and care pathway (incorporated into the Smart Contract)
  • Micropayments are triggered after each care package has been completed
  • Penalties are built into the Smart Contract and are assessed automatically if Provider fails to meet quality metrics (e.g. readmission rates, infection rates, revision rates, etc.) or poor outcomes (e.g. PROM, Oxford scores)
blockchain healthcare illustrative example
payment triggers
2. Ongoing
  • Patient experiences symptoms (e.g. increase pain, reduce mobility etc.)
  • Patient visits GP (Physician) or contacts Insurer directly (based on policy guidelines)
  • Patient accesses Insurer policy automatically using Private Key
  • Insurer automatically routes referral to Orthopaedic Consultant or Provider inline with policy
  • Patient commences journey through care pathway (e.g. pre-op, op, post-op, discharge, follow up, etc.) and is treated by the Provider against a pre-agreed set of protocols (consultation, imaging, pathology, implant, physiotherapy, etc.) with the Insurer
  • Provider feeds data into Electronic Patient Records (EPR). Standard data linked to specific non identifiable Patient Public Key and is published automatically onto the Blockchain via API
  • Insurer automatically validates treatment against pre-agreed care pathway and protocols and automatically triggers payment (see Payment Triggers to left)

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