System and method for processing payment bundles

• US 10,262,374 B2
• Filed: 05/13/2014
• Issued: 04/16/2019
• Est. Priority Date: 05/18/2011
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Sultan, Jay, Downs, Howard, Hoerle, Dale
• Primary Examiner(s): Chng, Joy
• Application Number:
  US14/277,037
• Publication Number:
  US 20140249864A1
• Time in Patent Office: 1,799 Days
• Field of Search: 705 2- 3, 705 4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/00 Payment architectures, schemes or protocols apparatus for performing or posting payment transactions G07F7/08, G07F19/00; electronic cash registers G07G1/12
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.

Claims

1. A process implemented by a payment bundling administration system for creating a patient event, triggering a payment bundle associated with the created patient event and repricing individual provider claims in accordance with the payment bundle comprising:

receiving, at the payment bundling administration system,

(a) a first web service call from a first core claims processing system including a claim reimbursement pricing request, the claim pricing request including at least one data set including specific data from an individual provider claim for reimbursement for at least one medical service rendered to a patient; and

(b) a second web service call from one of the first core claims processing system, a second core processing system and a medical service provider including non-claim information;

analyzing, by payment bundling logic of the payment bundling administration system, the at least one data set, non-claim information or the combination of the at least one data set and non-claim information to determine if a patient event should be created and trigger an associated payment bundle;

wherein the non-claim information includes at least one of an authorization and a pre-bundle notification indicating that a patient event will be created;

determining, by the payment bundling logic, that a patient event should be created;

creating, by the payment bundling logic, a patient event and triggering the associated payment bundle, wherein the patient event has an associated patient identification (ID) and includes multiple individual provider claims for medical services rendered to the patient over a preliminary date range;

searching, by the payment bundling logic, at least a first database of the payment bundling administration system to identify any previously received individual provider claims that are included in the multiple individual provider claims of the associated patient event, wherein the search compares a patient ID for each previously received individual provider claim to the associated patient ID and compares a date for each previously received individual provider claim to the preliminary date range;

repricing, by a pricing engine of the payment bundling administration system, an amount that should have been paid to a provider of each identified previously received individual provider claim that matches associated patient ID and occurred within the preliminary date range in accordance with pre-established rules defining the associated payment bundle; and

responsive to the first web service call, reporting, by the payment bundling administration system to the first core claims processing system, the repriced amount that should have been paid to providers of each identified previously received individual provider claims in the associated payment bundle.

2. The process in accordance with claim 1, wherein the data set further includes specific data from more than one individual provider claim.

3. The process in accordance with claim 1, further comprising:

receiving, at the payment bundling administration system, a web service call from one of the first core claims processing system and a second core claim processing system including an additional data set including a patient ID and a date for one or more additional individual provider claims;

comparing, by the payment bundling logic, a patient ID for each additional received individual provider claim to the associated patient ID and comparing a date for each additional received individual provider claim to the preliminary date range;

repricing, by the pricing engine, an amount that should have been paid to a provider of each additional received individual provider claim that matches associated patient ID and occurred within preliminary date range in accordance with pre- established rules defining the associated payment bundle; and

reporting, by the payment bundling administration system, the repriced amount to be paid to providers of each additional received individual provider claim in the associated payment bundle.

4. The process according to claim 1, further comprising after repricing each identified previously received individual provider claim and reporting to the first core claims processing system:

receiving, at the payment bundling administration system,

(c) a third web service call from one of the first core claims processing system and the second core claim processing system including at least one of a second data set including second specific data from a different individual provider claim and

(d) a fourth web service call from one of the first core claims processing system, the second core processing system and a medical service provider including second non-claim information;

determining, at the payment bundling logic, based on the received second data set that at least one of the identified previously received individual provider claims should no longer be included in the associated payment bundle;

repricing, at the pricing engine, at least one of the identified previously received individual provider claims in accordance with the determination; and

responsive to the third web service call, reporting, by the payment bundling administration system to the first core claims processing system, a result of the repricing.

5. The process according to claim 4, wherein repricing in accordance with the determination includes determining a payment amount according to a different payment bundle.

6. The process according to claim 4, wherein repricing in accordance with the determination includes determining that fee-for-service payment applies.

7. The process according to claim 1, wherein the non-claim information originates from the second core processing system or a medical service provider.

8. A process implemented by a payment bundling administration system for prospectively creating a patient event, triggering a payment bundle associated with the created patient event and repricing individual provider claims in accordance with the payment bundle comprising:

receiving, at a payment bundling administration system a first web service call from a first core claims processing system including a claim reimbursement pricing request for, a first individual provider claim for at least one medical service rendered to a patient;

analyzing, by payment bundling logic of the payment bundling administration system, the first individual provider claim to determine if a patient event should be created and trigger an associated payment bundle;

determining, by the payment bundling logic, that a patient event should be created;

creating, by the payment bundling logic, a patient event, assigning a patient identification (ID) to the patient event and triggering the associated payment bundle, wherein the patient event includes multiple individual provider claims for medical services performed over a preliminary date range, said preliminary date range including at least one future date;

searching, by the payment bundling logic, at least a first database of the processing system to identify any previously received individual provider claims that are included in the multiple individual provider claims of the associated patient event, wherein the search compares a patient ID for each previously received individual provider claim to the associated patient ID and compares a date for each previously received individual provider claim to the preliminary date range;

repricing, by a pricing engine of the payment bundling administration system, an amount that should have been paid to a provider of each identified previously received individual provider claim that matches the associated patient ID and occurred within the preliminary date range in accordance with pre-established rules defining the associated payment bundle; and

responsive to the first web service call, reporting, by the payment bundling administration system to the first core claims processing system, the repriced amount that should have been paid to providers of each identified previously received individual provider claims in the associated payment bundle;

wherein the repriced amounts that should have been paid to the providers of each identified previously received individual provider claim are zero.

9. The process according to claim 8, further including pricing, by the pricing engine, an amount to be paid to the provider of the first individual provider claim to be zero.

10. The process according to claim 8, further comprising:

receiving, at the payment bundling administration system, a second web service call from the first core claims processing system including a second claim reimbursement pricing request for, a second individual provider claim for at least one medical service rendered to a patient;

analyzing, by the payment bundling logic, the second individual provider claim to determine if it is included in the associated payment bundle;

determining, payment bundling logic, that the second individual provider claim is included in the associated payment bundle and that the second individual provider claim triggers an episodic payment amount for the patient event; and

responsive to the second web service call, reporting, by the payment bundling administration system to the first core claims processing system, that the episodic payment amount should be paid.

11. The process according to claim 10, further comprising:

receiving, at the payment bundling administration system, a third web service call from the first core claims processing system including a third claim reimbursement pricing request for a third individual provider claim for at least one medical service rendered to a patient;

analyzing, by the payment bundling logic, the third individual provider claim to determine if it is included in the associated payment bundle;

determining, by the payment bundling logic, that the third individual provider claim is included in the associated payment bundle and that the third individual provider claim should be priced to zero, wherein the third individual provider claim is received by the payment bundling administration system after the second individual provider claim; and

responsive to the second web service call, reporting, by the payment bundling administration system to the first core claims processing system, that the third individual provider claim should be priced to zero.

12. The process according to claim 10, wherein the episodic payment amount for the patient event is the entire amount to be paid for the multiple individual provider claims for medical services performed over the preliminary date range.

13. A process implemented by a payment bundling administration system for prospectively creating a patient event, triggering a payment bundle associated with the created patient event and repricing individual provider claims in accordance with the payment bundle comprising:

receiving at a first time, at a payment bundling administration system a first web service call from a first core claims processing system including a first claim reimbursement pricing request for a first patient related data set including a first individual provider claim for at least one medical service rendered to a patient;

analyzing, by payment bundling logic of the payment bundling administration system the first individual provider claim to determine if a patient event should be created and trigger an associated payment bundle;

determining, by the payment bundling logic, that a patient event should not be created after analyzing the first individual provider claim and determining, by a pricing engine of the payment bundling administration system, a first amount to be paid to the provider of the first individual provider claim, wherein the first amount is greater than zero;

receiving at a second time, at a payment bundling administration system a second web service call from the first core claims processing system including a second patient-related data set;

analyzing, by the payment bundling logic, the second patient related data to determine if a patient event should be created and trigger an associated payment bundle;

determining, by the payment bundling logic, that a patient event should be created after analyzing the second patient data set;

creating, by the payment bundling logic, the patient event and triggering the associated payment bundle, wherein the patient event includes at least the first individual provider claim; and

repricing, by the pricing engine, an amount that should have been paid to a provider of the first individual provider claim to zero and responsive to the first web service call, reporting by the payment bundling administration system the repriced amount to the first core claims processing system;

determining by the payment bundling logic, that the second patient-related data set includes a second individual provider claim for reimbursement and that the second individual provider claim triggers an episodic payment amount for the patient event;

responsive to the second web service call, reporting to the first core claims processing system, by the payment bundling administration system that the episodic payment amount should be paid.

14. The process according to claim 13, wherein the second patient-related data set contains non-claim information.

15. The process in accordance with claim 13, wherein the non-claim information includes at least one of an authorization and a pre-bundle notification indicating that a patient event will be created.

16. The process according to claim 13, further comprising:

receiving, at the payment bundling administration system a third web service call from a first core claims processing system including a second claim reimbursement pricing request for, a third data set including a second individual provider claim for at least one medical service rendered to the patient;

analyzing, by the payment bundling logic, the second individual provider claim to determine if it is included in the associated payment bundle;

determining, by the payment bundling logic, that the second individual provider claim is included in the associated payment bundle and that the second individual provider claim triggers an episodic payment amount for the patient event; and

responsive to the third web service call, reporting, by the payment bundling administration system to the first core claims processing system, that the episodic payment amount should be paid.