Real-Time Benefit Coordination Across Therapies

A single source of truth for benefit eligibility and payment status across all therapies prevents paying for the same service twice. This directly reduces claims leakage, a multi-billion dollar problem in healthcare. For example, a patient receiving physical therapy and chiropractic care for the same injury would have their benefits tracked on-chain, automatically preventing overlapping reimbursements.

Replace weeks of manual faxes and calls with instantaneous, automated verification. Providers submit claims to a shared ledger where coordination of benefits (COB) rules are executed via smart contracts. This slashes accounts receivable (AR) days and improves provider cash flow. A real-world pilot by a major payer showed a reduction in COB resolution time from 45 days to under 48 hours.

Every transaction—eligibility check, payment, and adjustment—is immutably recorded. This creates a tamper-proof audit trail that simplifies compliance with regulations like HIPAA (for audit logs) and ERISA. Auditors can cryptographically verify the entire history of a claim, reducing the cost and time of annual audits. This is critical for risk management and defending against fraud investigations.

A coordinated ledger enables value-based care and bundled payment models across multiple providers. All parties—hospital, specialist, rehab center—can trust the shared financial data, allowing them to focus on outcomes rather than payment disputes. For instance, an oncology bundle covering chemo, radiation, and supportive care can be administered transparently, ensuring each provider is paid accurately and promptly based on pre-defined milestones.

Automate manual processes for benefits investigation, claims status inquiries, and payment posting. This significantly reduces FTE (Full-Time Equivalent) costs in back-office operations. One health plan estimated that automating COB with a shared ledger could save over 200,000 manual work hours annually. Staff can be reallocated to higher-value tasks like patient advocacy and complex case management.

Clean, synchronized, and time-stamped financial data across all therapies becomes a powerful asset. This enables accurate predictive modeling for cost trends, identification of care gaps, and fraud detection. High-quality data feeds into existing BI tools, allowing CFOs to make strategic decisions based on a complete picture of multi-therapy spend and outcomes.

Eliminate manual claims adjudication between primary, secondary, and tertiary payers. A smart contract automatically applies benefit rules, calculates patient responsibility, and triggers payments in a single transaction. This reduces administrative overhead by up to 70% and cuts payment cycles from weeks to minutes. Example: A pilot with a regional payer network used this to resolve coordination of benefits (COB) disputes instantly, saving an estimated $12M annually in administrative costs.

Provide providers with a single, immutable source of truth for patient coverage and pre-authorization status across all plans. This eliminates denied claims due to outdated information. Key benefits include:

• Reduced claim denials by verifying eligibility in real-time.
• Faster patient onboarding with instant verification.
• Auditable compliance trail for all authorization decisions. A major hospital system pilot saw a 15% reduction in claim rework and improved patient satisfaction by streamlining the intake process.

Give patients a clear, real-time view of their financial obligation after all payer calculations are complete. A shared ledger shows the exact breakdown of insurer payments, patient deductibles, and co-pays before service is rendered. This increases patient collections by setting accurate expectations and enables flexible payment plans via smart contracts. Pilot data shows providers improved point-of-service collections by over 40% and drastically reduced bad debt write-offs.

Create an immutable, timestamped audit trail for every transaction across the payment lifecycle. This deters fraudulent claims by making double-billing and phantom procedures easily detectable. The cryptographically-secured ledger simplifies compliance audits for HIPAA and payer regulations, reducing audit preparation time and associated costs. A health plan estimated $8M in annual savings from reduced fraud investigation and streamlined regulatory reporting.

Encode complex value-based care agreements and fee schedules directly into smart contracts. Payments are automatically released upon verification of performance metrics or service delivery, removing manual reconciliation. This accelerates capitation payments and pay-for-performance incentives. An Accountable Care Organization (ACO) pilot automated incentive payments for quality metrics, cutting distribution time from 90 days to 7 days and improving cash flow predictability.

Securely share necessary clinical data (with patient consent) between providers and payers on a permissioned blockchain to validate medical necessity. This supports prior authorization and ensures payments align with covered services, reducing costly post-payment reviews. The shared data layer prevents disputes and improves payment integrity. A pilot integrating EHR snippets with claims processing reduced clinical review requests by 30%, speeding up clean claim approval.

Target a high-volume, manual process like Prior Authorization for Physical Therapy. Implement a private blockchain network with one provider group and one payer.

• The Pain Point: 15-20 minute manual submissions, 30% rejection rates requiring rework.
• The Blockchain Fix: Smart contracts auto-validate patient eligibility and therapy codes against the payer's policy, providing instant approval or a clear denial reason.
• Real Example: Aetna's pilot with PokitDok reduced prior auth turnaround from days to seconds for specific CPT codes, cutting administrative costs by over 60% for those transactions.

Expand the network to coordinate benefits across Physical Therapy, Occupational Therapy, and Chiropractic care for a defined patient cohort (e.g., workers' compensation).

• The Pain Point: Siloed treatment plans lead to duplicate services, billing conflicts, and poor outcomes.
• The Blockchain Fix: A shared, immutable ledger allows all authorized providers to view treatment history in real-time. Smart contracts enforce benefit caps and coordinate visit limits across disciplines.
• ROI Driver: UnitedHealthcare reported that care coordination programs can reduce duplicate testing and services by 10-15%, directly improving margins.

Integrate the validated treatment record from the blockchain directly into the claims processing system, creating a 'Golden Record' for payment.

• The Pain Point: Post-treatment claims adjudication is fraught with disputes, leading to lengthy accounts receivable cycles.
• The Blockchain Fix: Services pre-authorized and recorded on-chain are auto-adjudicated. The immutable audit trail eliminates disputes over what was approved and delivered, enabling straight-through processing.
• Quantifiable Benefit: Pilot data from Change Healthcare shows blockchain-based claims can reduce dispute resolution time from 45 days to near-zero, dramatically improving cash flow.

Leverage the aggregated, anonymized dataset from the pilot for advanced analytics and new revenue streams, justifying full enterprise rollout.

• The Business Case: The clean, structured data on therapy outcomes, utilization, and cost becomes a valuable asset.
• Monetization Paths:
  • Provider Networks: Sell insights on most effective treatment pathways.
  • Payer Analytics: Model risk and set premiums with unprecedented granularity.
  • Life Sciences: Provide real-world evidence for drug and device efficacy.
• Strategic ROI: This transforms a cost-center project into a profit-center initiative, funding further digital transformation.