Automated Real-Time Claims Adjudication

A single source of truth on a shared ledger prevents the same claim from being submitted to multiple insurers. Smart contracts automatically flag inconsistencies in treatment codes, dates, or provider details. For example, a major European health insurer reduced fraudulent claims by 22% in a pilot by cross-referencing immutable treatment records.

Automate manual steps: eligibility checks, policy verification, and coordination of benefits. Smart contracts execute pre-defined business rules, removing back-office labor. Key savings include:

• Elimination of manual data entry and reconciliation.
• Reduced need for claims adjusters for routine cases.
• Automated payment routing to providers and reinsurers. A PwC analysis estimates blockchain can reduce administrative overhead in claims processing by up to 80%.

Turn weeks of processing into minutes. When a claim meets all coded conditions (e.g., pre-authorization, in-network provider), the smart contract triggers automatic payment from insurer to provider. This:

• Boosts provider satisfaction and network loyalty.
• Improves insurer's cash flow predictability.
• Enables real-time analytics on claim patterns. Pilot programs in property insurance have shown settlement times reduced from 30 days to under 3 minutes.

Every transaction and rule execution is immutably logged, creating a perfect audit trail. This simplifies compliance with regulations like HIPAA, IFRS 17, or Solvency II. Auditors can verify processes in real-time instead of sampling paper trails. Benefits include:

• Automated regulatory reporting straight from the ledger.
• Dramatically reduced audit preparation costs.
• Proven adherence to internal policies and payer contracts.

Replace opaque "claim pending" status with real-time transparency. All parties (patient, provider, payer) see the same claim status, required documents, and payment timeline. This reduces inquiry calls by over 40% and significantly improves Net Promoter Scores (NPS). A leading US health network reported a 35% decrease in provider service center calls after implementing a transparent claims status portal powered by blockchain.

The Pain Point: Traditional claims can take 30-90 days to settle, tying up capital and frustrating providers. The Blockchain Fix: Smart contracts auto-adjudicate claims against immutable policy rules and provider contracts in real-time.

• Example: Aetna's pilot with blockchain reduced claim status inquiries by 50% and accelerated payments.
• ROI Driver: Reduces Days in Accounts Receivable (DAR), improving provider cash flow and patient satisfaction.

The Pain Point: Up to 30% of healthcare costs are administrative, driven by manual data entry, reconciliation, and dispute resolution. The Blockchain Fix: A single, shared source of truth for patient eligibility, provider contracts, and payment rules eliminates redundant verification.

• Automates reconciliation between payer, provider, and patient statements.
• Eliminates costly intermediaries and manual back-office processes. Quantifiable Benefit: For a mid-sized payer, this can translate to $15-25M in annual operational savings.

The Pain Point: Fraud, waste, and abuse cost the US system $100B+ annually. Audits are manual, slow, and prone to errors. The Blockchain Fix: Every transaction—from eligibility check to final payment—is timestamped, cryptographically signed, and immutable.

• Enables real-time fraud detection algorithms.
• Provides a verifiable, granular audit trail for regulators (HIPAA, SOX) in seconds, not weeks. Business Justification: Reduces compliance penalties and audit preparation costs by creating a self-verifying system.

Impact on the Balance Sheet:

• Reduces Locked Capital: Faster claims cycle frees up billions in working capital currently stuck in the payment pipeline.
• Lowers Reserves: Improved fraud detection and accuracy reduces the need for large financial reserves against faulty claims.
• Predictable Cash Flows: Real-time adjudication turns unpredictable receivables into a predictable, automated revenue stream. Bottom Line: This isn't just an IT project; it's a liquidity and financial integrity initiative with a clear ROI on capital employed.

Acknowledge the Challenge: Full industry adoption is a marathon. Start with a controlled, high-value pilot. Recommended First Use Case: Prior Authorization or High-Cost Specialty Drug Claims.

• Why? These are complex, costly, and involve multiple parties—perfect for demonstrating blockchain's coordination value.
• Builds Trust: A successful pilot creates the coalition needed for broader rollout. Key Success Factor: Partner with a technology provider that understands enterprise integration, not just cryptocurrency.