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/ACH

Claims 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.

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/ACH

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: