Automated Prior Authorization Platform

The Pain Point: A provider's office spends days faxing forms, making phone calls, and waiting for payer responses, delaying patient care.

The Blockchain Fix: Smart contracts automatically verify patient eligibility, coverage rules, and medical necessity against immutable records. Real-time adjudication slashes approval times from weeks to seconds, as demonstrated in pilot programs by Humana and UnitedHealth Group.

• Key Benefit: Accelerate revenue cycles and improve patient satisfaction.

The Pain Point: Payers and providers employ thousands of staff for data entry, status checks, and reconciliation of authorization requests.

The Blockchain Fix: A single source of truth on a shared ledger automates verification and audit trails. This reduces administrative FTEs by an estimated 30-50%, directly targeting the $8.6B annual cost of manual processing identified by the Council for Affordable Quality Healthcare (CAQH).

• Key Benefit: Redirect human capital to patient-facing roles and complex case management.

The Pain Point: Opaque processes create compliance risks and vulnerability to fraud, waste, and abuse (FWA), costing an estimated $68B yearly.

The Blockchain Fix: Every authorization step is time-stamped, permissioned, and immutable. This creates an automatic audit trail for regulators (HIPAA, CMS) and enables advanced analytics to flag anomalous patterns. Anthem's blockchain trials have shown promise in reducing fraudulent claim submissions.

• Key Benefit: Mitigate regulatory risk and recover lost revenue from FWA.

The Pain Point: Siloed EHR and payer systems require costly health information exchanges (HIEs) and custom APIs, creating integration headaches.

The Blockchain Fix: The platform acts as a neutral data utility. Providers submit once; payers access a standardized, verified record. This model, similar to Avaneer Health's network, reduces integration costs and breaks down data silos that hinder coordinated care.

• Key Benefit: Achieve true interoperability while cutting IT integration expenses by up to 40%.

The Business Case: A typical mid-sized health system processing 50,000 authorizations annually can justify the investment through hard savings.

Quantifiable Benefits:

• Labor Savings: $1.2M (reduced FTEs)
• Faster Payments: $800k (reduced A/R days)
• Compliance/FWA: $500k (risk mitigation)

Total Annual Benefit: ~$2.5M against a platform implementation cost of $2-3M. Real-world pilots by Mayo Clinic have demonstrated similar efficiency gains, validating the ROI model.

The Pain Point: Fee-for-service models struggle with the complex, longitudinal data sharing required for value-based contracts and prior authorization for advanced therapies.

The Blockchain Fix: The ledger securely tracks patient outcomes and treatment pathways across providers. This enables automated fulfillment of value-based contract terms and streamlined auths for specialty drugs, a growing pain point. Proof-of-concepts in oncology show how this accelerates life-saving treatments.

• Key Benefit: Future-proof operations for the shift to risk-sharing and personalized medicine.

Manual prior auth costs the US healthcare system an estimated $31 billion annually in administrative overhead. A blockchain platform automates verification, reducing processing time from days to minutes. Key benefits:

• Eliminate redundant data entry by creating a single source of truth for patient eligibility and coverage rules.
• Automate rule execution with smart contracts, removing manual review for standard cases.
• Example: Aetna's pilot with blockchain reduced prior auth turnaround for certain procedures by over 70%, directly cutting administrative FTEs and operational costs.

The average prior authorization delay is 8-14 days, directly impacting patient outcomes and satisfaction. Blockchain enables real-time, transparent status tracking. Key benefits:

• Provide instant, auditable decisions for pre-approved criteria via smart contracts.
• Give providers and patients a real-time dashboard to track request status, eliminating frustrating phone calls.
• Example: In a Mayo Clinic proof-of-concept, blockchain-based auth for imaging services provided determinations in under 5 seconds, dramatically improving the patient and provider experience.

Regulatory scrutiny (HIPAA, CMS rules) demands impeccable audit trails. Blockchain's immutable ledger provides a tamper-proof record of every decision, rule applied, and data access. Key benefits:

• Automate compliance reporting with a permanent, timestamped chain of custody for all auth data.
• Simplify audits by providing regulators with direct, read-only access to a verifiable history.
• Mitigate fraud risk through cryptographic integrity, making it nearly impossible to alter historical records or fabricate approvals.

Fragmented systems between payers, providers, and PBMs create data silos. Blockchain acts as a neutral data layer, enabling secure, permissioned sharing without centralized control. Key benefits:

• Establish a universal patient identifier (via hashed/encrypted data) to seamlessly link records across networks.
• Standardize data formats (e.g., FHIR on-chain) to ensure consistent rule execution.
• Example: The Synaptic Health Alliance, a consortium including Humana and UnitedHealth, used blockchain to create a shared provider directory, reducing data discrepancy issues that directly impact auth accuracy.

Justification requires hard numbers. A typical enterprise deployment shows ROI within 18-24 months. Sample calculation for a mid-sized payer:

• Cost Reduction: Save $12.50 per manual auth (labor, overhead). At 500,000 auths/year = $6.25M annual savings.
• Revenue Protection: Reduce claim denials and delays from auth errors, protecting 2-5% of premium revenue.
• Implementation Cost: ~$2-3M for integration, smart contract development, and change management.
• Net Result: Clear positive ROI with ongoing operational leverage.

Success depends on choosing the right technology partner. Look for platforms that prioritize enterprise integration, regulatory alignment, and consortium governance. Critical evaluation criteria:

• Proven Interoperability: APIs for seamless connection to existing EHR, CRM, and claims systems.
• Consensus Model: Permissioned (e.g., Hyperledger Fabric, Corda) for controlled member access, not public chains.
• Consortium Readiness: Experience facilitating multi-party agreements and governance frameworks.
• Focus on solutions that solve the business process, not just showcase the technology.