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Provider Credentialling

Section 1 - Intro

Business Problem / Opportunity

For health plans to offer the services of providers, by law and to be assured they are offering the members of their plan high quality, qualified services they must verify provider credentials. Credentials are the claims made by the provider about their qualifications, liability coverage, licenses and good standing in their profession. Sole practitioners and large practice organization also need to produce business records and their tax payer identifiers.

This process occurs initially when a provider enrolls in a plans' networks and then at recurring, regulated intervals.

Every plan has to do this for every provider with whom they want to transact. This process is time consuming, clerically intensive, paper-driven and error prone, and has to be done with quality to not fall foul of the regulations.

The result of this is a contract between the provider and plan, in which the provider agrees to abide by certain terms and the plan agrees to pay specific service fees often directly to the provider rather than the member. The provider has an incentive to participate in this agreement to receive a guaranteed payment.

Current Solution

This is either a semi-automated or manual system because there is very little information about a providers' claims that is available in certified digital form. The collected information must end up in digital form to be by regulation disseminated to members over the Web in a provider directory and published in handbooks. The process involves clerical staff faxing, calling and writing letters to academic institutions, and licensing bodies, or scraping license data off states' web sites; the NPPES npi site and the IRS' web site. Third parties provide this as a service by doing the same work, introducing a level of doubt in the process. Credit checking agencies are consulted. Some do searches on social media. Providers themselves sign a letter on penalty of perjury to attest to the accuracy and truthfulness of their claims.

The information is presented to a committee to rule on the veracity and acceptability of the claims and can be a bottleneck in the process of approving (or denying) the application. Committee members may be biased in their opinion by having contact with the applicant or hearing industry hearsay.

Regulations mandate that the plan back-up their confidence in the provider by visiting them on a regular schedule and completing pro-forma assessments - a costly time consuming process. Patient and member complaints and assessments are input into the assessment and have lower credence and weight without the force of regulations behind them.

Why a Blockchain?

The credentialing process could be greatly improved if provider claims could be consumed by plans (and consumers) from relevant block chains. A global academic blockchain that maintained verifiable claims about University-awarded qualifications would be consulted to verify academic and medical degree claims. A licensing authority-maintained ledger could be consulted to verify claims about medical licenses. In the US medical licenses are issues by the states, in other countries such as the UK it's the National General Medical Council. In order to prescribe drugs a provider might also hold an Drug Enforcement Agency (DEA) license, about which information could be maintained on a blockchain.

The National Provider Identifier, is centrally maintained by the National Plan and Provider Enumeration System (NPPES). It can be consumed as a large csv file updates to which are published monthly. It creates a unique identifier for organizational and individual providers as terse reference to these entities in claims processing. It also is a candidate for a block chain to be maintained by the owners of the identifiers about which it makes claims.

Maintaining verified provider financial records in a distributed ledger would allow them to be selectively consumed by plans to ensure a provider was solvent and obviate plans having to refer to third party agencies. Being able to verify a billing provider's tax payer id and keep this synchronized with changes in practice ownership would great improve plans' tax reporting.

User Stories


Section 2 - States and Transactions

Section 3 - Requirements

requirements/use-cases/use-case-provider-credentialing.txt · Last modified: 2018/03/12 23:54 by Adrian Blakey