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
Pharmacy/Homecare benefits Claims and
Revenue Cycle Management and analytics 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.

Access average insurance prices for healthcare service within a specified area. This information provides consumers with transparency into potential cost savings when deciding whether to pay upfront or to submit a claim

Access average cash prices of a specific health care service with in a geographic area. This information allows consumers to make smarter decisions regarding where to obtain services and how to pay for them.

Once a provider issues a prescription, this API assists the patient in finding a Network pharmacy nearby.

Access to EHR based on consent
By Specialist
By Hospital
By Insurance

Platform and Technology

Marketplace

Seniorcare1.healthygx.com
Mobicloud.healthygx.com

Blockchain Enabledment

http://poc.jeadigital.com:3000z

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