Before we get into the subject matter at hand, take a moment to think about the following scenario that many are all too familiar with:
Imagine a person goes to their medical provider and is informed they need surgery. They schedule the surgery and goes to the medical facility only to find out that it has to be rescheduled because the provider was not able to verify the person's insurance. The person returns on the new scheduled date and the same thing happens...
In the midst of the pandemic, I needed an emergency eye procedure. I was lucky that my provider was able to quickly verify my coverage with my insurance company and I was able to get the treatment I needed. During my follow-up exam, I met another patient who also needed an emergency eye procedure. If he didn’t get it, he risked retinal detachment, a condition that could lead to blindness if not treated in time. While we were in the waiting room, the man told me that he had already been to the office twice before to have the procedure, but was sent home because the provider hadn’t been able to connect with the man’s insurance company to verify coverage. I don’t know what happened to the man, whether he got the surgery in time to avoid retinal detachment or whether his condition deteriorated.
So, how do we as an industry proactively prevent these types of situations from occurring?
Creating the "Internet of Healthcare"
If we want to create real transformation in healthcare, we need a new infrastructure blueprint—one that doesn’t add additional features on top of a fractured system. We need an infrastructure that starts from the bottom up.
Mr. Hanson additionally notes that "the issue isn’t that we lack innovation to fix the problem. The issue is that we’re focused on fixing the wrong problem."
The key is for the industry to leverage blockchain and other technologies to create a neutral network through which healthcare organizations, patients, and other key stakeholders can access accurate, timely information in real time — an Internet for healthcare -- which is a main focus for Mr. Hanson and Avaneer Health.
Here's how it works:
First, payers and providers commit data to the cloud and allow it to be discoverable based on permissions that are set by each party. Users can connect to the network via the cloud, where the ID keychain and master index locates the information requested and matches it to the data available, then delivers it to the requestor. The intermediary—Avaneer Health—provides certification, end-point validation, an immutable audit trail, cybersecurity, and compliance. Use cases include eligibility verification, prior authorization, and real-time access to accurate, complete medical records.
The network also connects with rich solution providers like revenue cycle management companies, telehealth platforms and others that are involved in care coordination or the business of healthcare. This eliminates the need for payers and providers to build and maintain connections with multiple systems. Fewer touchpoints means fewer opportunities for security issues, not to mention reduced IT costs and resources needed to manage those gateways.
It's Time to Act
Whether or not the industry will accept blockchain as the main technology to fix the healthcare system is still up for debate, but the truth of the matter is that technology is the crux of the solution.
One key issue with the healthcare industry -- particularly healthcare revenue cycle -- is that the processes and systems are out-of-date and still remain reliant on paper documentation like EOBs. As reported in the 2021 CAQH Index, we've seen an increase in adoption of electronic remittances, but 36% of payments still remain partially or fully manual.
In order to achieve Mr. Hanson's "Internet of Healthcare," the industry will need to either eliminate these paper documents, which it has yet to prove it can do, or utilize AI and machine learning technologies to electronify these PDF and paper-based payments and correspondence letters into EDI 385 files that can be used by other systems -- creating the necessary data to encapsulate the patient medical record.