Hyperledger Project
Healthcare Working Group (HCWG) Payor Subgroup Meeting
August 28, 2018
Resources:
Chat: https://chat.hyperledger.org/channel/healthcare-wg (you can use your LFID to login)
Github: https://github.com/hyperledger
Wiki: https://wiki.hyperledger.org
HCWG Wiki: https://wiki.hyperledger.org/groups/healthcare/healthcare-wg
Public lists: https://lists.hyperledger.org
Meetings: https://wiki.hyperledger.org/community/calendar-public-meetings
Linux Foundation Antitrust reminder: https://www.linuxfoundation.org/antitrust-policy
Chris Cole is a pre auth SME
What’s an authorization?
Prior authorization - based on some set of rules, or other mandates, laws
Who submits pre auth? The person who wants to get paid is accountable (hospital itself)
In patient notification - restricted to member is going to be hospitalized, skilled nursing, confinement of some kind
1. determine whether you need prior auth
2. seeking the requests - put info together, here’s everything about the service i want to provide and is it approved
3. I submitted request and i want to understand the status of the request
4. sometimes more records are required based on what you asked to do. Follow on query
I want to have a knee surgery
Are all the elements around the member themself - (date of birth, etc.)
Check eligibility - (active coverage? Which product?)
Where is the surgery going to be done? Each setting has unique rules.
What? Procedure is knee surgery, these certain codes are associated
Why? Damage or problems, Diagnosis codes
Date/s? How many units during what time period?
Billing provider - ABC surgical assoc is the biller
Rendering doctor - Dr Jones
We may ask for additional information - particular codes sent in trigger a questionnaire or to upload certain types of records - clinic team to access the request needs additional information
This entire request is wrapped into one data ball and gets a unique identifier then it’s routed, business rules engine, routed to a reviewer set,general surgical review, work queue and a person is going to apply some clinical judgment on this
If it’s approved there is generally a clock counting down to the final decision
Approved or denied
If approved, electronically we notify the asker
If denied, more rules and regulations
Right of appeal
Why was this denied?
Any other kinds of information about what they can do about the negative decision
If in authorization I wanted to do knee procedures A and B
Say yes to one and no to the other - called partial
The no is treated like a denial with right of appeal, etc
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Flag, routine, emergent, emergency
Behavioral health and emergency requests are turned over very quickly
As people do their job through the pool, status changes are reflected
Pain points?
A lot of the things we talked about rely on a person coming to a screen to do part of it. Standardized transactions have more latitude
A lot to like around making this space more standard, picking up the pace, reducing manual touch points
A custom set of questions is not supported - non standard is a problem
What are the scenarios you feel are not standard? If there is an exchange of information on blockchain that eliminate issues?
Once something is pre approved, how long does it take to get paid? Information is sent to the claim platform in real time. Claim platform is waiting for a claim that matched. Claim comes in, this service matches the authorization, claim paid
Outcome - part of your benefit requirement, line up at point of payment, if I can’t do that then it’s not a good process
Precision on authorizations is used to predict upcoming expenses
What percentage are handled manually v automatically?
60% based around benefit design, goes through without human intervention
With the right additional info you could increase that percentage
If you authorize something 100% of the time, why are you requiring a pre auth?
Next steps: what areas can blockchain be applied to?