How AI and blockchain can transform the payment process
At Optum, we believe blockchain and artificial intelligence (AI) will benefit health care. They provide new ways to reduce administrative costs and decrease the total cost of care. And payer and provider CIOs have an important role to play in deciding how these technologies will be best deployed.
Consider insurance verification as a place to start
An initial area to consider applying blockchain and AI is within the current payment process, specifically the pre-service phase of insurance verification.
Lack of access to complete and up-to-date benefits and medical eligibility data is a pain point for payers, providers and patients. It also leads to errors and reworked claims that contribute to an estimated $200 billion in annual administrative waste.1
Providers struggle with point-of-care pricing and time-of-service collections, which can affect cash flow. Payers may be billed for patients out of their network. Or they may not receive enough information to determine coverage. Patients can be confused about their financial responsibility.
Blockchain and AI can help health care providers and payers exchange data and streamline benefits verification and medical eligibility checks. This can increase transparency and reduce confusion. It allows all parties, especially the patient, to understand their financial responsibilities.
Blockchain for a robust data exchange
Blockchain is changing the way we share, store and process data. It can create a time-stamped, tamper-proof record of transactions that can be accessed by trusted partners. It could provide a way to protect information, but also allow it to be accessed in a secure way.
If you can create a shared, secure network among a trusted group of payers and providers that conforms to antitrust and privacy laws, you could avoid the back and forth that goes into chasing down eligibility and benefits verification. The result is more efficiency in a competitive marketplace. But that only scratches the surface of what the payer and provider relationship could be.
Payers and providers who are thinking about how to apply blockchain can work to identify inefficient transactions that drain resources for both. They start by getting into the habit of sharing basic information using blockchain technologies. Then they can advance to using blockchain for more complex transactions.
AI and machine learning for richer insights
AI and machine learning rely on large amounts of accurate data to analyze and predict. Blockchain can keep the data secure, organized and flowing between peer-to-peer connections. The two technologies complement each other.
Using the shared data available through blockchain, AI supports predictive analytics and automation of repetitive processes. Within the pre-service phase of the payment process, it can help predict financial obligations.
For example, a provider wanted to address unpaid bills. Optum connected the provider’s records system with data about payer benefits and patient copay requirements. This enabled the system to analyze the data and calculate the patients’ share of the cost at the point of service. The provider was able to request payment on the spot, rather than mailing out bills.
This helped the provider increase up-front collections by 20%. Ninety-three percent of the time the provider received an estimate from Optum that outlined the patient responsibility for a given procedure.2
When health systems automate these processes and provide instant access to this type of information, they can refocus their limited resources on other tasks.
Optum Tech Talks
Through collaboration, payer and provider tech leaders can lead efforts to remove complexity and friction from the payment process – starting with one of the most painful transactions – benefit and eligibility verification.
Doctor John Kontor and former CIO Dave Chennisi offer insights into the roles CIOs and tech leaders can play.
Video: Payer and Provider CIOs Can Create A More Efficient Payment Process
NARRATOR: Through collaboration, payer and provider tech leaders can lead efforts to remove complexity and friction from the payment process – starting with one of the most painful transactions – benefit and eligibility verification. Doctor John Kontor and former CIO Dave Chennisi offer insights into the roles CIOs and tech leaders can play.
NARRATOR: Why should payer and provider CIOs focus on verification of benefits and medical eligibility?
DAVE: An awful lot of expense is spent right now on administration in a way that doesn't provide a direct benefit to the patient. If we can reduce the cost of sharing information about eligibility and about benefits, the more that we reduce costs there the more spend is available on the medical side
JOHN: Payers and providers are spending an inordinate amount of money on supporting this process both for technology and through the human side of the process. So any approaches that can reduce some of that friction, automate where we can, and reduce the burden on providers and provider staff from having to do the human side of this manual work to get authorization, ensure payment, ensure coverage, etc. will dramatically improve provider experience in both the provision of care and their ability to get paid for it.
NARRATOR: How can CIOs uncover solutions that improve access to benefits and eligibility data?
DAVE C: From both a business and from an IT perspective, they’ve got a role to play in helping the health plan navigate challenges related to how to share insurance verification information to providers. It's got to be seamless and it's got to be directed to the providers’ workflow. When I served as a CIO I spent time engineering approaches around our website, around our portal that would provide information to providers. And while that was useful on one level I pretty quickly found that it wasn't drawing new providers to the portal or the tools that we had set up for them. So the real key on this front, insurance eligibility front, and really any front I think, where you're dealing with provider engagement is to allow the information to be shared with them in the tool that they use, in the course of their normal work activities as opposed to having them go to a separate place to access information.
JOHN: It's going to be some time before we have a complete end-to-end solution that automates electronically all of the steps of determining coverage, determining site of service, recommending alternative coverage therapy and telling folks what it's going to cost out of pocket. So my advice to CIOs is to not wait until all of those problems can be solved at once but to strategically prioritize those parts of the process that we can improve today. An example of that is if a CIO can engages with a payer like United and through technology provided from both Optum and their EHR vendor, which can greatly ease the process of determining coverage for specific medications that are providers ordering out in real time at the point of care. That provides I believe one of those near-term opportunities for CIO to have an outsized impact on this whole process. 49:16
NARRATOR: What capabilities are required for technology solutions to address eligibility and benefits?
JOHN: First and foremost you just have to keep up with that changing insurance landscape, so provide a continuous data stream to the point of care through EHR's and tell providers, does the patient have coverage. If they do have coverage what's, what is that coverage, how much is it going to cost them out of pocket and is their site of service-- are there site of service limitations around any of that. And being able to do that in a way that is seamlessly up to date and ready at a moment's notice for providers is going to be key because we only have the attention of providers for a few seconds at best as they're making these decisions to help advise them and their patients that are often sitting in the room with them at the time as to whether the patient covered and how much it's going to cost. We know for at least a couple of the major EHR vendors, that this capability of taking in payer data and using that to highlight to providers whether a patient is eligible or not is, is really coming down the pipeline quickly. So again engaging with your EHR vendor very early in this process, so you can be ready to reap this benefit right away.
NARRATOR: How do CIOs prepare to implement strategies around collaboration and sharing data?
DAVE C: That is the 64 million dollar question which is how do you create a sense of collaboration that benefits both parties? And to do that I think you've got to look at transactions where both parties are incurring costs overhead and other debt that's unnecessary to the mission at hand. We work with our clients to help create that information plan for the payer to look forward to where they want to have their business be some time down the road, measure how well their current infrastructure stacks up against that goal, and help put together a plan to either remediate aspects of their legacy infrastructure which don't facilitate some of the technology changes and technology transactions that we're talking about here, remediate them or introduce new capabilities around it.
JOHN: Provider organizations, including their I.T. leaders ought to be directly engaging with their major payers and in their market today. All of the payers are interested in improving the efficiency and effectiveness of this process and they are more than willing to provide data where they can and where the EHR's and other technology systems are able to receive that. Through some of these payer-provider collaborations, we have the unique opportunity and CIO's in this moment in time have a unique opportunity to actually bring that hope to fruition and really significantly improve care experience with both patients and providers.
NARRATOR: Thank you for listening. Visit optum.com/CIO to get more health IT insights for CIOs and technology leaders.
How to get started
Provider and payer CIOs who want to transform the payment process using blockchain and AI can start by assessing their existing IT resources and infrastructure.
As health plans deploy new transactions and new technologies, it’s important to consider core legacy systems and address questions like:
- What kind of quality tests do we need to apply?
- How do we accept data?
- What kind of vetting will need to be done before data can be shared?
- Will the answers differ by transaction?
- Is there a need for enterprise data warehouse strategies to tackle larger and more diverse data sets?
By answering questions like these, IT leaders can measure how well their current infrastructure supports their goals. They can then put together a plan to fill the gaps. IT leaders can focus on incremental changes that move their organizations forward at their own pace.
The goal is to share information in a way that benefits each party’s digital workflows. Where possible, sharing tools should seamlessly integrate into existing systems, including the electronic health record (EHR).
Another important step is to let vendors know this is a priority. Provider CIOs can work with EHR vendors to encourage them to develop native capabilities to support data exchange.
An example of that type of capability is PreCheck MyScript®. This makes it easy to run a pharmacy trial claim and get real-time prescription coverage detail for patients who are UnitedHealthcare benefit plan members. When physicians use the tool, they change the prescription to a lower-cost alternative 30 percent of the time.3
Once leaders understand current capabilities, they can start to plan for where they want their business to go. They can look for areas of improvement and set a timeline for completing them.
The more we reduce the cost of sharing information about eligibility and benefits, the more spend is available on the medical side to help patients.– Dave Chennisi, Senior Vice President, Optum Advisory Services – Payer
Find support through collaboration
Deploying new technology can be a challenge for CIOs who face the work of balancing day-to-day tasks with future planning. It’s important to create partnerships that can help leaders promote strategies to invest in the right technology solutions.
It’s never too early to start talking about aligning and collaborating among payers and providers as well as other vendors.
It will take time and effort to integrate data and use blockchain and AI. But the technologies should make collaboration easier, as they promise security and privacy.
Shared benefits of shared data
With blockchain and AI, we have reason to be hopeful that we're going to see improved information exchange throughout the entire payment process.
A lot of money is spent right now on administration that doesn’t provide a direct benefit to the patient. If we can reduce the cost of sharing information about eligibility and benefits, more dollars will be available for medical care.
Transparently exchanging data makes it easier to navigate systems. This allows all parties to access the information they need to make the right decision at the right time.
No longer will patients find themselves sharing information between providers or facilitating information exchange between a payer and a provider.
The payoff will be a more simplified and streamlined system that results in fewer claims denials and lower administrative costs.
A lack of access to complete and current data that supports medical eligibility and verification of benefits is one of five key pain points highlighted in the Optum Payment Nexus infographic. Explore the pain points and read about collaborative solutions for addressing each.
1Institute of Medicine of the National Academies. The Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. 2013. ncbi.nlm.nih.gov/books/NBK207218/.
2Optum client results.
3Optum client results.
Senior Vice President, Optum Advisory Services – Payer
With more than 30 years in health care, Chennisi leads teams in systems implementation and integration projects. These projects span core administrative claims adjudication, medical management, business intelligence/data warehouse and customer relationship management applications. Prior to Optum, he was CIO at Texas Children’s Health Plan.
Senior Vice President, Optum Advisory Services – Provider
Dr. Kontor leads Provider Technology Services, which helps clinical organizations drive IT strategy, optimize IT systems, and reduce system costs and administrative burden. He received his doctor of medicine from the University of Florida, Gainesville; and his BA in health policy from Boston University. He practiced internal medicine for 14 years.