# Healthcare

<details>

<summary>Why blockchain?</summary>

Blockchain is a payment system that is:

<mark style="color:red;">Secure</mark>
\ <mark style="color:red;">Instant</mark>
\ <mark style="color:red;">Zero-fee</mark>
\ <mark style="color:red;">24/7/365</mark>
\ <mark style="color:red;">Global</mark>
\ <mark style="color:red;">Transparent</mark>
\ <mark style="color:red;">Immutable</mark>

</details>

<details>

<summary>Healthcare payment types</summary>

<mark style="color:red;">Claims Reimbursement</mark>\ <mark style="color:red;">Patient Payment</mark> \ <mark style="color:red;">Premium Collection</mark>\ <mark style="color:red;">Payroll</mark>\ <mark style="color:red;">Pharmacy Claims</mark>

```
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
```

</details>

<details>

<summary>Claims Reimbursement</summary>

<mark style="color:red;">PBM → Pharmacy</mark>

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.

</details>

<details>

<summary>Patient Payment</summary>

<mark style="color:red;">Patient → Provider/Pharmacy</mark>

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.

</details>

<details>

<summary>Premium Collection</summary>

<mark style="color:red;">Employer/Individual → Payer</mark>

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.

</details>

<details>

<summary>Payroll</summary>

<mark style="color:red;">Healthcare Organization → Employee</mark>

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.

</details>

<details>

<summary>Pharmacy Claims</summary>

<mark style="color:red;">PBM → Pharmacy</mark>

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.

</details>

```
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

<figure><img src="/files/EeNoFL9YGyuw2hwCRx4H" alt=""><figcaption></figcaption></figure>

### ACH HEALTHCARE VOLUME 2024

**YoY Growth:** Payments: 4.6% Dollars: 11.3%\
**Total Payments:** <mark style="color:red;">510.17 million</mark>\
**Total Dollars Transferred:** <mark style="color:red;">$2.65 trillion</mark>

### <mark style="color:purple;">HEALTHCARE EFT PAYMENT OPTIONS</mark>

<figure><img src="/files/sqa7SMmpO6DF2d0kWuoP" alt=""><figcaption></figcaption></figure>

### REGULATION

The Patient Protection and Affordable Care Act (ACA)

***

<mark style="color:purple;">NOTES</mark>

There are three electronic-funds transfer systems in the United States. The other two, Fedwire and CHIPS, are
&#x20;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\ <br>

<mark style="color:purple;">RESOURCES</mark>

[NACHA\_HC\_Fact\_Sheet.pdf](https://www.caqh.org/hubfs/43908627/drupal/core/phase-iii/reference/NACHA_HC_Fact_Sheet.pdf)\
[Trends in Healthcare Payments](https://www.caqh.org/hubfs/CORE/State%20of%20the%20Industry%20Trends%20in%20Healthcare%20Payments_072524.pdf)\
[Electronic Payments in Healthcare](https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=1002\&context=ichita_transactions)\
[GS HC Conference](https://s201.q4cdn.com/374903510/files/doc_presentations/2024/06/Goldman-Sachs-Conference-June-2024_FINAL_GS-Format_Clean-SEC-VERSION.pdf)\
[The Digital Revolution comes to US Healthcare](https://www.anderson.ucla.edu/documents/areas/adm/acis/library/DigitalRevolutionGS.pdf)\
[William Blair Healthcare 2025](https://www.williamblair.com/-/media/downloads/eqr/2025/williamblair_consumer-centric-healthcare-2025-update.pdf)\
[US Bank Healthcare Insights Report](https://www.usbank.com/dam/en/documents/pdfs/corporate-and-commercial-banking/healthcare-payments-insight-report.pdf)

<http://healthcare.nacha.org/>\
<https://www.nacha.org/healthcare-resources>

[Breaking Down a Broken Healthcare Payments System](https://hps.md/blog/breaking-down-a-broken-healthcare-payments-system/)\\

[Skyrocketing Hospital Administrative Costs, Burdensome Commercial Insurer Policies Impacting Patient Care](https://www.aha.org/guidesreports/2024-09-10-skyrocketing-hospital-administrative-costs-burdensome-commercial-insurer-policies-are-impacting)


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