Physicians and Providers

For Healthcare Providers

The platform and related protocols will seek to simplify and automate the onboarding, contracting, and operational processes between healthcare providers and payers. The platform is made available to any licensed provider of healthcare services and the intent is to create a gateway for providers to use in their relationships with employers and payers. The goal is to enable providers to have a single platform that can be used for enrollment, credentialling, contracting, operational integration to third parties, payment submission and reconciliation, and an analytics platform.

Self-Enrollment and Contracting

The ultimate glue to the entire protocol are the contracts between OpenNetworks and the healthcare providers. Healthcare providers will self-determine their reimbursement rates using an interactive application that includes the most recent data on their agreed rates with local or national health insurers, HMOs or PPOs.

The contracting functionality will include credentialing, policy and procedures, and online contract execution. Once a provider is credentialed onto the network, all employers and payers accessing the network contracts will be required to accept this single source of credentialing as a prerequisite for network access. Credentialing includes verification of education, licensure, board certification, professional experience, malpractice history, peer references, criminal background check, DEA registration and requires updates for continuing education confirmation. This resource will be made available to any employer, insurer or individual to encourage this single-entry for providers wishing to simplify their compliance with multiple payers.

Peer to Peer Contracting with Employers, Unions, Governments and School Systems:

A fundamental feature of OpenNetworks is the enablement of direct contracts between employers and healthcare providers, including availability to all capabilities provided by third parties that have been integrated into the platform.

Operational Integration

A central goal is to simplify a healthcare providers ability to work with payers, as well as with local and national employers using a single operational interface. The OpenNetworks platform and related protocols rely on standard interfaces for the primary transactions between a provider and payer.

Healthcare claims submissions will be possible via Electronic Data Exchange (EDI), via direct submission, through clearinghouses, or through API-connected electronic health record (EHR) systems. Electronic prior authorizations (ePA) or EDI submissions of HIPAA-compliant 278 transactions will be initially enabled, with APIs for payers to integrate their own direct links for phone, fax or mail requests.

Payments will be possible through Electronic Funds Transfer (EFT) or Direct Deposit (ACH). Related EDI for payment-related information, such as Form 835 transactions, will also be enabled through the platform.

Clinical sharing of EHR information for selected payers will be at the option of the participating healthcare provider and be enabled using Smart on FHIR APIs.

Payments Options and Value Based Payment Administration

The core of the platform is initially based on fee for service payments. Healthcare providers will be given a range of options for pricing, including a single price for all payers; unique payment rates for direct pay by local or national employers; and differential rates for HMO, PPO or EPO plan offerings.

It is anticipated that a range of integrated services, offered by independent organizations, will be available to healthcare providers in the network. Those may include bundled payment administration, population health administration and services, specialty carve-out programs and other forms of value-based purchasing. These value-based payment programs may be operated and run by insurers, HMOs, disease management companies, population health management companies or other organizations who comply with the OpenNetworks protocols and seek to access contracted payment arrangements through the network.

Analytics Platform

All participants in the OpenNetworks platform will have access to data from the network, based on their role and the permissions in their contracts. This includes the Machine-Readable Files that all health insurers and hospitals are required to make publicly available, as well as de-identified data stored on the network that could be used for modeling and analytics purposes.

Ownership and Governance

OpenNetworks, Inc will operate a multi-stakeholder cooperative. The primary stakeholders will be healthcare providers and employers. A non-profit organization, governed by an independent board of directors representing health care providers, employers, and insurers will be the parent entity. To date, all funding has been provided through private donations from individuals.

The primary operating subsidiary will be a multi-stakeholder cooperative (OpenNetworks, LLC) which will build and manage the cooperative network and payment platform. The operating subsidiary will issue securities as a multi-stakeholder cooperative to raise funds for platform development and management, enable contributors to receive ownership and dividend distribution rights, and to encourage network participation.

Only a minority of board members of OpenNetworks (the nonprofit) are allowed to hold financial stakes in the LLC at one time. Furthermore, only board members without such stakes can vote on decisions where the interests of limited partners and the nonprofit mission may conflict – including any decisions about making dividend payments to network participants or payouts to investors and employees.

This structure is intended to increase our ability to raise capital while still serving our mission. This structure has similarities to health care nonprofits who create for profit subsidiaries. Examples include the Mayo Clinic (the nonprofit) creating and operating Mayo Clinic Ventures; or Mozilla, the nonprofit behind Firefox web browser, creating and operating a for-profit subsidiary to generate revenue through partnerships, advertising and other means. Khan Academy is the other versions of this approach.

OpenNetworks Platforms

A network platform and a payment platform are being created to implement the vision of this project. The two platforms interoperate to deliver the necessary functional capabilities. The network platform includes a contracting module, a credentialing module, and a profiling module. Our vision is that both network and the payment platforms can be used by any employer or payer, requiring a single enrollment by healthcare providers to serve multiple parties. Both platforms are being designed to allow ‘self-enrollment’ by healthcare providers and rapid onboarding for both the payers and providers of health services.

Funding and Network Building

We expect OpenNetworks, LLC will ultimately generate revenues and profits. Distributions of profits to the nonprofit parent entity are anticipated to someday allow us to continue expanding the scope of our mission and services.

Initial funding for the development of OpenNetworks has been provided by individual donors to OpenNetworks. We will seek to expand the number of contributors to this digital protocol as the project evolves. Upon formation of a multi-stakeholder cooperative, we will have an initial issuance of securities to raise funding to accelerate the build-out of the software and infrastructure. We presently anticipate issuing governance and financial interests in the Cooperative to healthcare provider organizations and employers who participate in the Cooperative.

Regulatory Compliance

The project is establishing procedures and protocols to assure compliance with HIPAA, Medicare and Medicaid regulations, the False Claims Act, the Stark Law, the Anti-Kickback Statute, and state-specific regulations. Payment Card Industry Data Security Standards will also be adopted by the platform.

The creation of a multi-stakeholder cooperative and the associated issuance of governance and financial rights for funding and rewards purposes, also subjects the protocol to expansive regulations. We anticipate that all activities will be compliant with state, federal and SEC rules and confer rights of proportional, or fractional ownership to holders.

Technical Considerations

Centralization/Decentralization. OpenNetworks will launch on an centralized AWS platform but is designed to enable a transition to decentralized storage and software solutions. Some features, such as privacy and identity management, may use permissioned blockchains. This balances the need for efficiency, control, simplicity, and maintenance, while eliminating the single point of failure of fully centralized systems. It also tempers risks of control by any single entity and the scalability concerns as the number of users and transactions increases. This approach is also more consistent with the challenges of regulatory compliance and privacy.

We will utilize cryptographic techniques, such as digital signatures and hash functions, to ensure the integrity and authenticity of data. This helps protect against unauthorized access and tampering. Ultimately moving towards a permissioned blockchain offers increased transparency, as participants can easily verify transactions and track historical data. This feature simplifies auditing processes and helps build trust among participants.

In a permissioned blockchain, access is granted only to authorized participants, which helps maintain privacy and control over sensitive information. Granular access controls can be implemented to further protect data and limit the visibility of transactions to specific participants. Permissioned blockchains have a smaller attack surface compared to permissionless blockchains, as they only allow authorized participants to join the network. This reduces the risk of malicious actors attempting to disrupt the network or manipulate data. And finally, permissioned blockchains can be tailored to the specific requirements of the healthcare industry, allowing for custom features, governance structures, and smart contract functionality.