CONCEPT & SOLUTION ROADMAP FOR EMERGING HEALTHCARE MODELS
Current healthcare challenges
- Managing the ubiquity of chronic illness
According to the World Health Organization chronic, “incurable” illnesses (or non-communicable diseases) are the leading cause of mortality worldwide and are directly responsible for 63% of all deaths annually. In addition to having a serious impact on health (morbidity), chronic illnesses also have a profound economic burden to society, both in terms of healthcare costs and productivity losses. - Caring for an increasingly aging population
As seniors age, their need for healthcare products and services increases significantly. - The increasing cost of labour; and 4. the adoption of new medical technologies.
Caring for an increasingly aging population
One of the primary reasons that healthcare is more expensive for seniors is that many are living with chronic conditions; in fact, approximately 60% of seniors are living with one or more chronic condition
Our healthcare system was not designed to provide healthcare to a population of seniors who would live into their eighties, often with multiple chronic conditions.
The solution to caring for an aging population lies in how and where care is provided to seniors.
Emerging Healthcare Models
COMMUNITY-BASED HEALTHCARE
Decentralizing health care by moving care out of resource-intensive institutions (such as hospitals), and into models of care delivery and even self-management in the home and community
CONNECTED HEALTHCARE
Using healthcare information technologies and processes to “Connect all parts of a healthcare
delivery system, seamlessly, so that critical health information is available when and where it is needed”
Failure of current delivery model
Provider Search
Clearing House
Transparency & Price
Scheduling & ID Management
Pharmacy Processing
Payments
Financing
Current healthcare systems were designed to operate in the legacy(data in silos) fee-for-service Payer/Sponsor model. They were implemented pre-Internet, pre-mobile, and are not interoperable.
Capture a piece of the $2.9T1 in healthcare delivery through real-time transactions and value- driven marketplaces
- CMS – National Healthcare Expenditure Estimate 2015, excludes Investment spending
- CAQH Index 2016
- NCBI source, 2014
- Indian healthcare expenditure estimate 50 to 60 Billion
Market opportunity
Reduce additional waste in health system due to
- Manual transaction processing
- Lack of care coordination
- Administrative complexity and time delays in revenue cycle
Our solution healthcare network eliminates inefficiencies and unlocks new business models by providing
- Interoperability
- Enhanced security and Privacy
- Access to new healthcare market models
Our platform enables new business models that create cost savings for sponsors, health systems and providers, while improving the patient experience through enhanced transparency, choice and control.
| Front end | Patient/Provider and Stake Holder access for Healthcare |
| Core applications | Modular applications
Revenue Transparency tools/Pre-Authorization / Scheduling / identity management |
| Back end | TPA/Insurance/Clearinghouse/Government |
| Back end | Infrastructure Centralized and Decentralized Systems ( Cloud/Mobile and Block Chain) |
Modules
Membership Management
Demographic Details
AADHAAR Details
Policy Details
Enrolment
Provider Management
Network and Empanelment
Cash Less
Provider wise tariffs
Contract Management
Transactions
Eligibility
Pre-Authorization
Claims Submission – Insurance, Medical information, and Billing information
Remittance advice
EHR – Medical Information Policy holder
Challenges
Data standards for exchange?
Identifiers
Customer ID – AADHAAR
Provider ID –
Payor ID –
Employer ID –
Proposed Solution
Payor Access
Provider Access
Platform Administration
SAAS – Centralized version to manage Paper/semi automated
Blockchain enabled version to manage fully automated provider-Payor management
API SERVICES
Identity / KYC
Health Care Business
Fair Pricing
Medical Insurance
Pharmacy
EHR
Identity/KYC and Provider/Payor Identification
Customer
Name
AADHAAR ID
Demographic details
Policy Details
Contact Details
MRN
Other
Details Specialist/Doctor
- Provider Name
- AADHAAR ID
Registration NO
Contact details
Hospital or healthcare institution
Name
Unique ID
Demographics
Other details
Payor/Employer
Name
Unique ID
Address
Type of sponsor
Other details
ELIGIBILITY AND PRE-AUTHORIZATION
Verify patient insurance coverage in real-time.
Access current health plan information such as deductable, max out of pocket, coinsurance, co-pay, limitations, and exclusions.
This data gives a snapshot of a person’s health coverage and serves as a starting point for many patient engagements.
CLAIMS SUBMISSION API
Submit claims electronically to payor, saving time and reducing overhead costs.
Improve clean submissions and decrease denial for faster reimbursement cycles
CLAIMS PAYMENT/ Remittance API
Receive real-time claims payment notifications and access full payment, denial, and electronic remittance advice details with Ease.
CLAIMS STATUS API
Check the current status of outstanding claims at any time.
Provide transparency into the revenue cycle by giving a comprehensive picture of where each claims stand.
SCHEDULING
Consolidate enterprise scheduling across all major EMRs including domestic solutions premises/cloud based.
Keep schedules up-to date in real time across multiple EMRs.
Enable patients to seamlessly access and book appointments online.
PATIENT ACCESS
Engage consumers in a single unified application that enables
provider search
appointment scheduling, eligibility checks,
claims submission, and payments
patient access solution e-commerce experience to healthcare
PROVIDER SEARCH
Search for providers based on biographical details, education, credentialing and other quality and business data.
This directory is one of the most inclusive and accurate provider directories available.
Fair Pricing.
Once a provider issues a prescription, this API assists the patient in finding a Network pharmacy nearby.
By Specialist
By Hospital
By Insurance
Platform and Technology
Marketplace
Blockchain Enabledment
HealthyGx Marketplace
HealthyGx a senior care services, digital eco system.
It provides access to services covering lifestyle, medication, nutrition, transportation and mobility.
Subscriptions , Ondemand services and Marketplace verticals.
Connects Customer to complete set of service providers Hospitals, Clinics, Doctors, Caregivers, Rehab centers, Home and Assisted Living facilities.
Health Chain Integration POC Insual Chain
On a high level, the solution is a state of art Blockchain example of claim processing in insurance process on Hyper ledger as platform
The peers on this process: insurance, police, repair shop and shop
When a shop peer sell a product or asset sells to customer,
Insurance: responsible for processing the claims
Police: responsible for verifying the theft claims
Repair shop: responsible for repairs
