Multi-Payer Coordination of Benefits

A shared, immutable ledger creates a single source of truth for patient coverage and payment history across all payers. This eliminates the primary cause of inter-payer disputes and the associated reconciliation labor.

• Real Example: Aetna and UnitedHealthcare can instantly verify a patient's primary vs. secondary payer status and previous adjudication, removing weeks of back-and-forth.
• ROI Driver: Reduces administrative costs for dispute resolution by an estimated 60-80%, directly improving payer margins.

Automated, rule-based settlement on the blockchain executes payments between payers in near real-time, not weeks. This dramatically improves working capital efficiency for providers and payers.

• Process Impact: Transforms a manual, batch-driven process into a continuous settlement engine.
• ROI Driver: Cuts the secondary payer payment cycle from 30-45 days to under 48 hours, unlocking trapped capital and reducing accounts receivable days.

Every eligibility check, claim adjudication, and payment is cryptographically sealed to the ledger. This creates an indisputable audit trail that satisfies stringent regulatory requirements (HIPAA, state DOI rules) and simplifies internal and external audits.

• Compliance Benefit: Automatically proves correct coordination order and payment calculations, mitigating compliance risk.
• ROI Driver: Reduces audit preparation time and potential fines, saving an estimated $200k+ annually in compliance overhead for mid-sized payers.

Patients receive accurate, upfront explanations of benefits (EOBs) because all payers are working from the same data. This transparency drastically reduces confusion and the subsequent flood of calls to member services.

• Member Impact: Clear, consolidated EOBs improve satisfaction and trust.
• ROI Driver: A leading health plan pilot showed a 25% reduction in COB-related member service calls, lowering operational costs and improving Net Promoter Score (NPS).

Smart contracts encode business logic (e.g., birthday rule, carve-outs) that executes automatically and consistently. This removes human interpretation errors and variance between payer systems.

• Accuracy Gain: Ensures 100% consistent application of COB rules across all transactions.
• ROI Driver: Eliminates the cost of reprocessing incorrect claims, which can account for 15-20% of a payer's COB operational expense.

The foundational blockchain layer enables secure, granular data sharing beyond claims. This paves the way for automated value-based care settlements and real-time care coordination across networks.

• Strategic Advantage: Positions the organization for next-generation payment models that require trust and automation between entities.
• ROI Driver: Creates the infrastructure to capture new revenue streams and partnerships, protecting against future disruption.

The legacy "pay-and-chase" model leads to overpayments and fraud. Blockchain creates an immutable, shared ledger where payment rules and claim status are visible to all authorized parties in real-time.

• Example: A patient with primary and secondary insurance submits a claim. Both payers see the adjudication history, preventing the secondary payer from overpaying based on incorrect primary payment data.
• Business Value: Direct reduction in recovery costs and fraudulent claims, protecting margins.

Today, coordination of benefits (COB) relies on faxes, phone calls, and proprietary portals, causing delays. Smart contracts can automate data requests and responses between insurers based on pre-defined business logic.

• Key Benefit: Drastically reduces administrative labor and accelerates claims processing from weeks to minutes.
• ROI Driver: Frees up staff from manual follow-up tasks, allowing reallocation to higher-value activities like customer service.

Providers spend excessive time determining patient coverage and navigating payer rules. A blockchain-based eligibility and COB system gives providers a single, authoritative view of a patient's active coverage and payment hierarchy.

• Operational Efficiency: Minimizes claim denials and re-submissions due to COB errors, improving cash flow.
• Quantifiable Impact: Studies show up to 15% of claims are delayed or denied due to eligibility and COB issues—a direct cost to provider revenue cycles.

Every eligibility check, payment determination, and data-sharing event is recorded on an immutable ledger. This provides a tamper-proof audit trail for state regulators and internal compliance teams.

• ROI Driver: Dramatically reduces the cost and time of compliance audits. Provides definitive proof of correct coordination of benefits logic application, mitigating regulatory and legal risk.

With a real-time, shared view of patient coverage and payment history, secondary payers can adjudicate claims immediately after the primary payer settles. This eliminates the current 30-60 day waiting period for patients.

• ROI Driver: Improves member satisfaction and retention scores (a key metric for insurers). Reduces call center volume related to claim status inquiries.

Blockchain's inherent ability to track asset provenance applies directly to claims. It becomes nearly impossible to submit the same claim to multiple payers without detection, as its entire lifecycle is visible.

• ROI Driver: Direct savings from fraud prevention. The National Health Care Anti-Fraud Association estimates healthcare fraud costs $68 billion annually; COB fraud is a significant component.

The complexity of COB makes it a perfect candidate for consortium blockchains. Leading payers are forming alliances to share infrastructure costs and define industry standards.

• Strategic Justification: Early participation positions your organization as an innovator, reduces future integration costs, and allows you to influence the standards that will govern the industry.