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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
First Claim
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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.

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