Decentralized Clearinghouse for Healthcare Claims

Eliminate the multi-day, manual process of matching provider claims with payer records. A shared ledger provides a single, synchronized version of truth, automating adjudication. This reduces reconciliation labor by 70-80% and cuts payment cycles from weeks to days.

• Real Example: A pilot by a major healthcare consortium reduced claim dispute resolution from 45 days to under 7 days, freeing up millions in working capital.

Immutable audit trails and smart contract logic prevent double-dipping and fraudulent claims. Each claim is cryptographically timestamped and linked to a patient record, making duplicate submissions impossible to process.

• How it works: Smart contracts automatically check claim hashes against the ledger before payment authorization.
• Business Impact: A leading P&C insurer reported a 15% reduction in fraudulent claim payouts within the first year of a similar blockchain implementation.

Transform regulatory audits from a quarterly scramble into a real-time, transparent process. Every transaction—submission, adjustment, payment—is recorded on an immutable ledger, creating a perfect audit trail.

• Key Benefit: Demonstrate compliance with regulations like HIPAA, SOX, or IFRS 17 instantly, reducing audit preparation time by over 90%.
• Real Value: This turns compliance from a cost center into a strategic asset, minimizing legal risk and potential fines.

Move from net-30 or net-60 payment terms to near-real-time settlement. Smart contracts can trigger payments automatically upon claim approval, improving cash flow for providers and giving payers precise control.

• Financial Impact: Providers improve Days Sales Outstanding (DSO), while payers can optimize their float. A regional hospital network pilot showed a $12M improvement in working capital efficiency.
• Mechanism: Use of programmable money (stablecoins or tokenized fiat) enables instant, final settlement.

The aggregated, anonymized data from the clearinghouse becomes a powerful asset. Analyze treatment outcomes, provider performance, and cost patterns to develop new data-as-a-service offerings or value-based care models.

• Example: Consortium members can license benchmark data to pharmaceutical companies for R&D or to providers for operational benchmarking.
• Strategic ROI: This transforms the clearinghouse from a utility into a profit center, generating recurring revenue streams.

A neutral, decentralized platform eliminates the need for any single entity to be the trusted intermediary. All participants—payers, providers, labs, patients—operate from the same cryptographically secured data set.

• Business Value: Reduces friction in forming new partnerships and scaling networks. Onboarding new partners becomes a technical integration, not a lengthy legal and trust-building exercise.
• Outcome: Faster ecosystem growth and reduced governance overhead, enabling innovation like bundled payments and cross-border claims processing.

Manually chasing other insurers for reimbursement is a slow, paper-heavy process. A decentralized clearinghouse automates subrogation by using smart contracts to instantly verify liability and execute payments between carriers upon claim settlement. This eliminates manual reconciliation and reduces recovery cycles from months to days.

• Real Example: A European motor insurance consortium reduced subrogation disputes by 70% and cut administrative costs by 40% using a shared ledger for accident data.

Fraudulent claims cost the industry billions annually. A permissioned blockchain allows insurers to securely and anonymously share indicators of fraud (e.g., suspicious provider patterns, claimant history) without violating privacy laws. This creates a collective defense network, making it exponentially harder for bad actors to exploit multiple companies.

• Key Benefit: Moves from reactive fraud investigation to proactive, network-wide prevention, directly protecting the combined ratio.

The quarterly or annual reconciliation between insurers and reinsurers is fraught with disputes over data. A single source of truth for ceded claims on a blockchain provides real-time, auditable records of exposures and payments. Smart contracts can automatically calculate and trigger reinsurer payouts based on predefined treaty terms.

• ROI Driver: Eliminates lengthy audit processes, reduces capital held in dispute reserves, and improves cash flow predictability for both parties.

In healthcare, payers and providers battle over coding errors, eligibility, and pre-authorizations. A decentralized network for claims submission and adjudication uses immutable records of patient eligibility, treatment codes, and provider contracts. Smart contracts automatically validate claims against policy rules, approving clean claims instantly and flagging exceptions.

• Real Movement: Major health insurers are piloting systems that have shown potential to reduce administrative costs by up to 30% and cut claim processing time from weeks to minutes.

During a natural disaster, insurers are flooded with claims, leading to slow payouts and customer dissatisfaction. A pre-configured blockchain clearinghouse can automate triage and payment for verified CAT claims. With IoT data (e.g., weather, seismic feeds) and smart contracts, parametric triggers can release immediate funds to policyholders, bypassing traditional adjuster delays.

• Business Value: Drives unparalleled customer satisfaction and retention during crisis events while reducing operational strain on claims teams.

Meeting regulatory requirements for claims handling (e.g., anti-money laundering, fair settlement practices) requires extensive, defensible documentation. Blockchain provides an immutable, timestamped audit trail for every action in a claim's lifecycle. Regulators can be granted read-only access to verify compliance in near real-time, transforming audits from disruptive events to continuous transparency.

• ROI Justification: Dramatically reduces the cost and risk of compliance audits and provides ironclad defense in litigation or regulatory investigations.