Healthcare
Why blockchain?
Blockchain is a payment system that is:
Secure Instant Zero-fee 24/7/365 Global Transparent Immutable
Healthcare payment types
Claims Reimbursement Patient Payment Premium Collection Payroll Pharmacy Claims
HEALTHCARE PAYMENT FLOWS
Claims Reimbursement (Payer → Provider)
1 Provider submits claim to Payer
2 Payer adjudicates claim
3 Payer sends ACH/check payment
4 Provider reconciles payment to claim
5 Provider handles denials/appeals
Patient Payment (Patient → Provider/Pharmacy)
1 Provider estimates patient responsibility
2 Patient pays via card/portal/check
3 Processor settles payment to Provider
4 Provider reconciles and bills outstanding
Premium Collection (Employer/Individual → Payer)
1 Payer invoices monthly premium
2 Employer/Member pays via ACH/check
3 Bank settles to Payer account
4 Payer updates eligibility/coverage
Payroll (Healthcare Organization → Employee)
1 Employer builds ACH payroll file
2 Bank processes direct deposits
3 Employee receives funds on payday
4 Employer handles exceptions/returns
Pharmacy Claims (PBM → Pharmacy)
1 Pharmacy submits real-time claim to PBM
2 PBM approves coverage and sets copay
3 Patient pays copay at counter
4 PBM pays pharmacy via EFT/ACHClaims Reimbursement
PBM → Pharmacy
1 Provider submits 837 (often via a clearinghouse) to Payer. 2 Payer adjudicates claim (allow/deny). 3 Payer sends ACH healthcare EFT (CCD+/TRN) or virtual card/check and issues 835 ERA. 4 Provider reconciles payment↔claim (auto reassociation via TRN from bank). 5 Provider handles denials/appeals as needed.
Patient Payment
Patient → Provider/Pharmacy
1 Provider estimates patient responsibility (POS or post-EOB). 2 Patient pays via card / portal / check (sometimes cash/HSA). 3 Processor settles to Provider; fees and timing depend on method. 4 Provider reconciles and bills any outstanding balance.
Premium Collection
Employer/Individual → Payer
1 Payer invoices monthly premium. 2 Employer/Member pays via ACH (still some checks). 3 Bank settles to Payer account. 4 Payer updates eligibility/coverage; employers often seek better funds-movement visibility.
Payroll
Healthcare Organization → Employee
1 Employer builds ACH payroll file (Direct Deposit). 2 Bank/ACH processes direct deposits. 3 Employee receives funds on payday. 4 Employer handles exceptions/returns.
Pharmacy Claims
PBM → Pharmacy
1 Pharmacy submits real-time claim to PBM (adjudication + copay set). 2 PBM approves coverage and sets copay. 3 Patient pays copay at counter (card/wallet/cash). 4 PBM pays pharmacy via EFT/ACH with remittance detail.
EFT PAYMENT FLOW
ACH HEALTHCARE VOLUME 2024
YoY Growth: Payments: 4.6% Dollars: 11.3% Total Payments: 510.17 million Total Dollars Transferred: $2.65 trillion
HEALTHCARE EFT PAYMENT OPTIONS
REGULATION
The Patient Protection and Affordable Care Act (ACA)
NOTES
There are three electronic-funds transfer systems in the United States. The other two, Fedwire and CHIPS, are not suitable for healthcare payments, as they address large-value payments and are more expensive to use.
Traditional vs Cost Plus Drugs:
Traditional: Manufacturer → Wholesaler → PBM → Pharmacy → Patient
Cost Plus: Manufacturer → Cost Plus (wholesaler/pharmacy) → Patient
JPMorgan Problem
High cost of care Accessibility and availability Implicit or unconscious bias in healthcare
RESOURCES
NACHA_HC_Fact_Sheet.pdf Trends in Healthcare Payments Electronic Payments in Healthcare GS HC Conference The Digital Revolution comes to US Healthcare William Blair Healthcare 2025 US Bank Healthcare Insights Report
http://healthcare.nacha.org/ https://www.nacha.org/healthcare-resources
Breaking Down a Broken Healthcare Payments System Skyrocketing Hospital Administrative Costs, Burdensome Commercial Insurer Policies Impacting Patient Care
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