Machine Learning and Blockchain Technologies Enable HSBlox’s RevBlox to Revolutionize Claims Management Challenges

Recognizing the difficult challenges healthcare providers and payers face with claims management in the era of value-based care, HSBlox, a technology company that is bringing innovation and transparent economics to the healthcare ecosystem, today announced the release of its patent-pending RevBlox™ solution.

While other solutions focus on charge-posting accuracy at a practice-specific level, RevBlox takes a multi-layered approach. Using continuous, adaptive and aware machine learning methods, the solution provides visibility at the payer contract, member plan, provider NPI, claim and service levels – unlike solutions that are rules-based. The intelligence gained is applied across practices.

RevBlox brings forward next-generation workflow and deploys advanced technologies, including machine learning and blockchain/private distributed ledger technology (DLT), to prospectively help providers reduce claims denials and secure payment of patient financial responsibilities for care. It also enables payers to create new levels of transparency around real-time adjudication of claims and reimbursement, as well as the immediate generation of explanation of benefits (EOBs) for members.

“Too many issues are corrected after they occur,” said Lynn Carroll, Chief of Strategy and Operations at HSBlox. “Providers dedicate an inordinate amount of time, money and personnel reworking and appealing claims denials and often are at risk of patients not paying their portion of the bill, especially in these days of high-deductible health plans. Payers also expend a tremendous amount of resources processing claims that should be automatic. Combining machine learning analytics and DLT smart contracts, we are taking a prospective approach that helps providers and payers avoid these issues.”

Avoiding, rather than reworking, denials

Claims denials are one of the greatest revenue cycle management challenges facing healthcare organizations. While the overall percentage of denials is small, the overall dollar amount is still considerable. In fact, one study showed that initial claims denials amounted to $262 billion in 2016. Given that The Advisory Board states that only two-thirds of these denials are recoverable, but 90 percent of claims denials are preventable, HSBlox believes that the focus should be on avoiding denials rather than recovering them.

RevBlox addresses this issue by using historical claim and payment data and applying proprietary machine learning algorithms and analytics to identify patterns of claims denials, as well as their causes. In addition to machine learning, rules-based edits, such as incorrect or missing codes and Medically Unlikely Edits (MUEs) or payer-specific edits, are also incorporated. Once the causes have been identified, providers can use this information to remediate issues at the source.

RevBlox calculates scores at the claim and service lines that show the likelihood of acceptance or denial. With the scores, and the explanation for the problems, providers can proactively correct problem claims prior to submission, further reducing denials.

Increasing claims transparency

The traditional process of gathering data about the specific benefit plan, eligibility, progress toward deductibles and out-of-pocket maximums, prior authorization requirements, application of fee schedules and other information is time-consuming and laborious. Add in human review and it can take days – or even weeks – until the provider sees what the payer will cover and how much the patient will owe.

RevBlox solves this issue with DLT smart contract approaches that have already been proven in the financial and supply chain verticals. Payers, providers and patients participate in a secure, private distributed ledger that ensures all information about the transaction can be viewed in real time by all participants. As result, payers can adjudicate claims in real time and return settlement statements, EOBs and even reimbursement in minutes if they choose.

In these days of high-deductible health plans (HDHPs), patient responsibility amounts can run into the thousands of dollars. According to The Advisory Board, patients with deductibles greater than $5,000 have only a 36 percent propensity to pay. Since the Centers for Disease Control and Prevention (CDC) states that nearly 40 percent of U.S. adults now have HDHPs, these factors put providers at more risk than ever of accumulating bad debt.

With a real-time EOB, providers can show patients what they will owe at the time services are rendered. Presenting this information while the patient is still in the office greatly increases the likelihood that the provider will be paid in full, especially if multiple payment options are involved, such as credit card/mobile payments, HSA or HRA accounts, and financing for larger expenses.

Opening financing options

The traditional financing option for hospitals is recourse-backed financing against its own resources. RevBlox makes it possible for providers to enlist financial institutions in offering new financial programs, including direct-to-consumer l****, similar to when consumers purchase a new vehicle. Once a real-time EOB is generated showing how much the patient will owe, the patient will have the option to pay immediately or request financing.

With RevBlox, providers can work with financial institutions to gather historical data related to patient payment patterns, and use RevBlox’s machine learning algorithms to deliver a predictive score for payment. Via DLT, financial institutions can then return tailored financing options in real time, while the patient is in the office. Patients and providers are able to make better decisions about expensive procedures, and neither is left with debt they can’t afford. From a compliance perspective, all parties to the financing transaction have an immutable DLT record of the transactions.

“Healthcare itself has advanced tremendously in the 21^st century thanks to technology,” Carroll said. “Unfortunately, in many aspects, the way we pay for it has not. RevBlox gives providers and payers the tools to solve the most pressing claims management issues proactively so that they can relieve the financial pressures they’re facing.”