Proposal to add new participant roles on Health Claims Exchange Protocol (HCX)

[ajitsingh2603]

Context

In response to the dynamic shifts within the health claims landscape, characterised by the rapid emergence of innovative technologies and the increasing involvement of diverse stakeholders, there is an urgent need to adapt and evolve the existing roles in the Health Claims Exchange Protocol (HCX).

The aim of introducing these new roles extends beyond merely refining existing processes. Instead, it is focused on enabling new-age ecosystem actors to perform expert functions within the claim management cycles. These roles are designed to empower specialised service providers and innovative companies to contribute their unique expertise towards streamlining claim adjudication processes, optimising revenue cycles, and ensuring compliance with evolving regulatory standards. By harnessing the capabilities of these actors, HCX can unlock new levels of efficiency, accuracy, and innovation within the healthcare claims ecosystem.

Therefore, this proposal advocates for the introduction of following new roles aimed at empowering new-age ecosystem actors to perform expert functions within Health Claims Management:

1. Technical Service Provider
2. Revenue Cycle Managers

Explanation of Roles

Technical Service Provider (TSP):
TSPs specialise in providing essential technical services such as OCR, AI/ML, auto adjudication algorithms, and more, facilitating efficient information processing and claim structuring for various ecosystem players. They could play a crucial role in accelerating claim adjudication processes and enhancing overall efficiency within the healthcare ecosystem. While TSPs do not directly adjudicate claims, their expertise in advanced technologies ensures seamless data exchange among healthcare entities. Examples of such organisations from the current HCX community could be - Renix Informatics, iAssist, etc.

Revenue Cycle Managers (RCM):
RCMs offer tailored services focused on optimising revenue cycles for healthcare facilities. By understanding the intricacies of hospital billing processes and reimbursement models, RCMs devise strategies to maximise revenue generation while minimising operational inefficiencies. Through rigorous quality assurance measures and comprehensive audits, they could ensure billing accuracy and regulatory compliance, ultimately enabling hospitals to allocate resources more effectively towards patient care and strategic initiatives. Examples of such organisations from the current HCX community could be -
ACN Healthcare, GMoney, etc.

Why we need new roles :

• Tailored Onboarding: Separating TSP and RCMP roles enables the possibility of tailored onboarding processes unique to each role. This approach fosters deeper trust in the participants joining the network.

• Enhanced Visibility and Analytics: This separation provides a more granular view of network activities, thereby improving analytics and insights into the network's operations.

• Better Access control : The addition of these roles facilitates better access control on platform APIs, ensuring that each participant has appropriate access rights based on their role and responsibilities. This granular access control enhances security and data privacy within theHCX platform, mitigating the risk of unauthorised access or data breaches.

Protocol Access groups :

HCX protocol assigns access groups to participant roles, tailored to their specific responsibilities and interactions within the ecosystem. Based on the initial understanding of these participant’s responsibilities, following access groups are proposed :

• TSPs - Access groups may vary based on the actor they are assisting within the healthcare ecosystem. TSPs could be assigned any of the access groups depending on their engagement with health service providers, payers, observers, or other entities.

• RCM - RCMs may require access groups such as "Observer" or "Claim Initiator," depending on their level of engagement with health service providers. This flexibility ensures that RCMPs have appropriate access rights to fulfil their responsibilities effectively, whether they are observing network activities or initiating claims on behalf of healthcare facilities.

We urge everyone in the HCX community to review this proposal, provide feedback, and suggest enhancements to ensure that the introduction of these new roles aligns with the goals and objectives of the broader healthcare ecosystem. Your insights and contributions are invaluable in shaping the future of HCX and advancing our collective mission of improving healthcare delivery and outcomes for all. Together, we can drive meaningful progress and innovation in healthcare claims management.