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Hyperledger Project
Healthcare Working Group (HCWG) Payor Subgroup Meeting
August 28, 2018

Chat: ​​channel/​healthcare-wg ​(you can use your LFID to login)
Github: ​​hyperledger
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Linux Foundation Antitrust reminder:

Chris Cole is a pre auth SME

  • Works at Care First 9 years - create population health tools
  • Director in provider application space

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

  • This member needs this service, and now I want to understand if some kind of permission is required

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

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?

groups/healthcare/2018_08_28_payor_notes.txt · Last modified: 2018/08/28 20:11 by Jennifer DeVivo