Insuring the Insurer

1. Customers approach a hospital service desk and present their credentials (this could be done prior to visiting a hospital also)
2. Hospital validates the necessary documents and submits pre-authorization from the insurer
3. Insurer tallies the claim against its policies / limits and sends a response
4. Hospital takes the general guidelines and continues to service the client with recommendations from field doctor, which is often checked against the pre-authorized limits and whether it is applicable or not by checking with the insurer.
5. After submitting a claim and before or during some procedures, patients often wait of steps 2-4 to be completed. This could happen more than once depending on the field doctor’s advice on the diagnostic tests and procedures to be performed
6. Upon completion, patients pay the remaining bills and collect all the originals before they are discharged
7. Hospitals settle the bill with the insurance company after providing copies of tests / procedures done The service request spans across multiple parties and hence delays are inevitable (step 2-4, 7).

The negotiation in these steps are further delayed because of veracity of the services requested and provided should be established. All this while, the customer is kept in the dark on where the approval process is held. The hospitals must provide all documents necessary for approval process which are needed by the insurance companies to eliminate fraud.

This clerical process introduces delays, errors, and miscommunication. For insurers, answering customer queries about approval is frustrating when it is held up in the hospital administration. Also, insurers can benefit in cost reduction by reducing the delays and by eliminating fraud if they can commit hospitals to a transparent process.

1. Customers approach a hospital service desk and present their credentials (this could be done prior to visiting a hospital also)
The hospital Dapp starts a transaction id for the customer and updates the status as ‘initiated’ in the blockchain. Customers and insurers get notified and can check the status at any time using the id

2. Hospital validates the necessary documents and submits pre-authorization from the insurer
The hospital Dapp changes the transaction from initiated to verified (if necessary can share verified data too)

3. Insurer tallies the claim against its policies / limits and sends a response
Insurers response is captured in the blockchain ledger along with necessary data and hospital is notified on the approval and limits immediately

4. Hospital takes the general guidelines and continues to service the client with recommendations from the field doctor – this is often checked against the pre-authorized limit and applicability through the insurer
The hospital Dapp, in real-time, can request for additional approvals and update the status of the request and customers can make a note of the same

5. After submitting a claim and before or during some procedures, patients often wait of steps 2-4 to be completed. This could happen more than once depending on the field doctor’s advice on the diagnostic tests and procedures to be performed
This step is not necessary as patients get a real-time window into the negotiation / approval between the insurer and hospital

6. Upon completion, patients pay the remaining bills and collect all the originals before they are discharged

7. Hospitals settle the bill with the insurance company after providing copies of tests / procedures done

From customers’ perspective an open and transparent system would benefit in understanding and mitigating the delays. From insurers’ perspective, they could save time in approvals and eliminate fraud if there is an immutable record of services requested / performed from the hospitals. Eventually, they can tally that with the final bill for any fraud.