In this study, we develop a Blockchain-based B-SAHIC (Secured and Automated Health Insurance Claim) processing system. The increase in the cost of health insurance adversely affects the services offered by the insurance company.
Health insurance system
Abuse: Inappropriate use of services, for example prescribing a patient medicine or tests that are not medically required but are covered by the policy. In the case of health insurance, the Policyholder receives health services from the networked healthcare and the service provider then submits claims to the Insurer.
Blockchain technology
To this end, to make it reflect the status of the majority, each node modifies its local copy of the Blockchain [18]. It can be customized with network members who can see and access the ledger.
Traditional (without Blockchain) solutions
In this chapter, there are related research works for the insurance industry and other sectors that use various technologies, such as data mining, big data, artificial intelligence and so on, in section 3.1, a research study using blockchain technology is in section 3.2, a gap in analysis with the definition of the problem in section 3.3. The system includes minimal machine learning knowledge to install and automate parameter selection.
Blockchain-based solutions
30] develop a computer-aided post-entry standardization method using a dictionary of disease names and also an anonymous linking system. They use HIPAA (Health Insurance Portability and Accountability Act of 1996) validations that process the data submitted for electronic data interchange (EDI) requirements and also allow the sharing of patients' data across multiple healthcare providers. According to HIPAA, the clearinghouse acts as an intermediary between the health care system and the insurance company to securely transmit the electronic claims while preserving patients' personal information.
By introducing Blockchain technology, they propose a decentralized insurance claims system, thus eliminating the role of the centralized clearing house.
Gap Analysis and Problem Definition
However, the authors have not actually implemented their idea, and no detailed fraud detection algorithm has been presented. Although a framework is proposed in [32] no detailed description of the actors, their roles including the relationship between them have been identified. Algorithms that can detect multiple submissions have been designed and implemented in a proper manner through smart contract chaincodes.
They did not actually implement their idea and no detailed fraud detection algorithm was presented. A user-friendly web-based interface has been designed and implemented through which users with all types of roles can easily interact with the Blockchain system depending on their respective roles and permissions. A simpler web-based interface was developed in [37], where all users have the same role and therefore no restriction is applied based on the user's role.
Although they have addressed privacy among different insurance companies, nothing has been mentioned about the privacy of stored user data in an insurance company system.
Types of health insurance claim
System model
Entity-Relationship (ER) diagram
Access to information
To achieve a common goal, business services and policies can be distributed among many members who participated in the network through smart contract [23].
Process of health Insurance Claim
Healthcare ID, Name, Location, Name Prof, Special Field, Disease Name, Dis ID, Price, Billing Details. When the Insured becomes infected with disease, she can go to the network health service provider for the purpose of cashless treatment and send her Insurance Card to them for verification. After the required treatments have been provided to the Insured, the Provider generates a bill and submits a Claim to the relevant Insurer together with all the copies of bills, evidence of treatments and diagnosis.
If it is an invalid claim or changes need to be made, the Insurer returns it to Healthcare and asks to provide sufficient and verified documents. However, if they find that the claim is valid, the amount claimed will be deducted from the Insured's life support portfolio as insurance cover and will make the payment to the service provider. The same thing happens with the request for reimbursement, with the exception of its presentation by the insured herself.
Unlike public Blockchain networks like bitcoin or Ethereum where anyone can participate, a private Blockchain network like Hyperledger Fabric is a permissioned distributed ledger network and accessible only to users who have been specifically invited to join or use the network .
Sequence of Messages
These requirements guide us to use permissioned private Blockchain with high efficiency and fast transaction speed, where a single organization owns the entire network and access is limited to only predetermined entities. In our study, we use Hyperledger Fabric for developing the secure and automated health insurance claims processing platform, which is an open source collaborative effort organized by the Linux Foundation. Provision of health services: This step represents that the client has the policy to receive the required health services and the service is provided by the health care.
Claim Request (reimbursement or no money): The claim request is submitted by the customer (reimbursement) or by healthcare (no money). Claim approval or rejection: The claim is approved or rejected by the insurance company. We have described the details of these steps in Section 5.3 where we have presented the necessary algorithms.
Business Model
In our system, the three actors – the customer, the insurer and the healthcare system – are the participants. Please note that they have permission to read/write the Blockchain (customer and healthcare) and execute smart contracts (the insurance company). Assets are anything that has virtual or physical values, for example policy details, customer details, treatment details, billing details, claim details, payment details, etc. Note that all attributes in our ER diagram (shown in Figure 4.2) can be considered assets.
In our system, it includes customer registration, treatment application, reimbursement request, cashless claim request, claim approval request and claim denial request.
Algorithms for the smart contracts
Request ID Consists of the treatment number applied for and the request delivery time in microseconds. The current business policy implemented through this algorithm ensures that a claim request will only be submitted successfully if all of the following conditions are met: 1) the customer is a valid customer, 2) the type of treatment is covered in their policy, 3) she has not applied for the same treatment before, 4) their total number of claims submitted this year (CTY) is less than their annual allowable number of claims (CL), and 5) the amount of their total claim amount (CMY) submitted this year is less than their annual claim amount (ML). When a claim is submitted by a customer (reimbursement) or a health care (no money), it will be accepted or rejected by the insurance company according to Algorithm 5. If all the conditions mentioned below are met, the requested amount will be given in full or partially under the policy for that particular treatment: 1) the client is a valid client, 2) the type of treatment is covered by her policy, 3) the amount claimed or the number of claims does not exceed the annual limits, 4) the client or care health care did not send the same claim request earlier, 5) the claimed amount submitted by the client or health care, is available in the client's life support portfolio, (6) manual validation of clients'.
Please note that eachClaimID is a unique number. This is the treatment number applied for that specific treatment, merged with the time of claim application submission in microseconds. This claim ID is automatically generated and stored in the blockchain when a request for a cashless or refundless claim is submitted. This transaction is visible to everyone connected to the network. The submitter (client or healthcare provider) cannot therefore simultaneously submit the same declaration request to multiple insurers.
Finally, the received claim amount will be deducted from the customer lifetime support (WA) portfolio amount.
Development Environment
For our front-end we used Nginx, an open-source high-performance HTTP web server, which is used as a web portal where the participants can communicate with each other.
CTY = CTY + 1
Distributed Ledger Storage Structure
In Hyperledger Fabric, a ledger can be split into two separate but related parts: (1) Blockchain and (2) World State. The Blockchain section contains the entire transaction history, while the world state section contains the current values of a range of ledger states and makes it easy to find the current state instead of going through all the transaction logs. The first is the OnChain transaction, where the transactions are recorded in the distributed ledger.
The second is the OffChain transaction, where transactions are recorded outside the Blockchain network. Note that Blockchains are recorded in OnChain while the states of the world are recorded in OffChain. Apache CouchDB is an open source document-oriented stateful database for chaincode indexing.
This index is used to query the current state of read-only data stored in the blockchain's ledger using JavaScript Object Notation (JSON) queries.
Security and Privacy
The application form for treatment, shown in Figure 6.5, is used by the client to apply for health services and will be recorded in the ledger for further processing of the injury. The customer inquiry message, shown in Figure 6.6, also returns the balance of the available amount in the customer's account. In addition, Healthcare is entitled to see only the name, age, gender, medical history and available quantity of the client.
In Figure 7.1, we looked at the average latency required to query from 1 to 1300 QPS (queries per second). Here, two peer nodes (peer0.org1.com and peer0.org2.com) represent the roles of client and healthcare provider, respectively. It can be seen from Table 7.2 that peer nodes, couchdb database servers and order nodes consume most of the resources.
In this case, all treatment payments made by the clients are only visible to the hospital and insurance company with which the patient registers. InProceedings of the 16th ACM SIGKDD International Conference on Knowledge Discovery and Data Mining, pages. InProceedings of the 17th ACM SIGKDD International Conference on Knowledge Discovery and Data Mining, pages.
![Figure 2.5: Performing transactions on the Blockchain[1].](https://thumb-ap.123doks.com/thumbv2/filepdfnet/10925075.0/17.892.130.770.489.775/figure-2-5-performing-transactions-on-the-blockchain.webp)
