Method of increasing efficiency in a medical claim transaction, and computer program capable of executing same

• US 10,289,804 B2
• Filed: 12/20/2004
• Issued: 05/14/2019
• Est. Priority Date: 01/21/2000
• 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: Chapman, Sherwood, Echeverria, J. Mikel
• Primary Examiner(s): Sorey, Robert A
• Assistant Examiner(s): Rapillo, Kristine K
• Application Number:
  US11/018,189
• Publication Number:
  US 20050108067A1
• Time in Patent Office: 5,258 Days
• Field of Search: 705 4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Claims

1. A method of interactively processing in real-time, using multiple inter-related menus accessible on a computer, a medical claim in a medical claim transaction initiated by a submission of the medical claim via an electronic medium to a medical plan provider on behalf of a patient making a visit to a medical service provider, the method comprising:

prior to a termination of the patient'"'"'s visit to the medical service provider;

receiving, at the computer, a request to process a medical claim, wherein the request to process a medical claim is provided to the computer and processed thereby in accordance with the multiple inter-related menus presented to a user via web pages on a display, the inter-related menus including a user role menu linked to a role activity menu, the role activity menu being linked to an activities menu, wherein the role activity menu assigns one or more activities to different user roles in the user role menu and defines access privileges to one or more activities within the activities menu, wherein a request to process a medical claim is an activity within the activities menu which is accessible in accordance with a user role assigned to a medical service provider user, and further wherein the medical service provider user is uniquely identified to the computer via a user menu which includes an item for receiving a one-way encrypted password from the user to identify the user as a medical service provider user prior to displaying the activities menu for a medical service provider user role, including the request to process a medical claim;

performing, by a computer, an analysis routine in accordance with the request to process a medical claim comprising;

identifying, by the computer, a most-recently-received medical claim for the patient received from the medical service provider, where the most-recently-received medical claim can be the medical claim or a different medical claim;

analyzing, by the computer, the most-recently-received medical claim in order to determine whether the most-recently-received medical claim is in condition for approval, the analyzing including one or more of checking an eligibility of the patient in a medical plan offered by the medical plan provider, comparing a medical claim history of the patient to the medical claim in order to check for a duplicate claim, comparing a contract between the medical service provider and the medical plan provider to a medical procedure to which the medical claim transaction pertains, and comparing a medical benefit of the patient in the medical plan to the medical procedure to which the medical claim transaction pertains, wherein comparing a medical benefit of the patient is performed in accordance with multiple inter-related menus including a benefits menu coupled to a revenue code menu, a service code menu and an accumulator menu for aggregating multiple accumulator items in the benefits menu;

determining that the most-recently-received medical claim is not in condition for approval;

rejecting, by the computer, the most-recently-received medical claim;

identifying, by the computer, at least one reason the most-recently-received medical claim was rejected and identifying, by the computer, an alteration to the most-recently-received medical claim that would place the medical claim in condition for approval;

transmitting, by the computer, a message containing information regarding the rejection of the most-recently-received medical claim and the at least one reason for rejection to the medical service provider via the electronic medium, wherein the message enables a creation of the different medical claim and the different medical claim represents an alteration of the most-recently-received medical claim;

analyzing, by the computer, the different medical claim in order to determine whether the different medical claim is in condition for approval, the analyzing including one or more of checking eligibility of the patient in a medical plan offered by the medical plan provider, comparing a medical claim history of the patient to the different medical claim in order to check for a duplicate claim, comparing a contract between the medical service provider and the medical plan provider to a medical procedure to which the different medical claim transaction pertains, and comparing a medical benefit of the patient in the medical plan to the medical procedure to which the different medical claim transaction pertains, wherein comparing a medical benefit of the patient is performed in accordance with multiple inter-related menus including a benefits menu coupled to a revenue code menu, a service code menu and an accumulator menu for aggregating multiple accumulator items in the benefits menu;

determining, by the computer, that the different medical claim is in condition for approval;

informing, by the computer, the medical service provider via the electronic medium that the different medical claim has been approved;

determining a monetary value to the medical service provider of the medical procedure to which the different medical claim transaction pertains;

determining a monetary value to the patient of the medical procedure to which the different medical claim transaction pertains;

wherein determining the monetary values to the medical service provider and the patient of the medical procedure includes

accessing a database storing a plurality of requirements and conditions for multiple claims, wherein the different medical claim meets at least some of the requirements and conditions for a first and second of the multiple claims,

scoring each of the first and second of the multiple claims in accordance with predetermined criteria related to each of the requirements and conditions of each of the first and second of the multiple claims the different medical claim meets;

determining the monetary values based on scoring results; and

informing the medical service provider via the electronic medium that the different medical claim has been approved and informing the medical service provider of the monetary values of the medical procedure to the medical service provider and to the patient; and

terminating, by the computer, the medical claim transaction.

2. The method of claim 1 wherein:

the electronic medium is the Internet.

3. The method of claim 1 wherein:

the analysis routine is completed within five minutes of the receipt of the medical claim.

4. The method of claim 1 wherein:

the method is transaction-based.

5. An interactive, real-time claims processing method using multiple inter-related menus accessible on a computer, comprising:

receiving, by a computer, a request for pre-approval of a medical claim for payment related to a medical procedure via an electronic medium on behalf of a patient of a medical service provider while the patient is in an office of the medical service provider for the medical procedure, wherein the request for pre-approval of a medical claim is provided to the computer and processed thereby in accordance with multiple inter-related menus presented to a user via web pages on a display, the inter-related menus include a user role menu linked to a role activity menu, the role activity menu being linked to an activities menu, wherein the role activity menu assigns one or more activities to different user roles in the user role menu and defines access privileges to one or more activities within the activities menu, wherein the request for pre-approval of a medical claim is an activity within the activities menu which is accessible in accordance with a user role assigned to a medical service provider user, and further wherein the medical service provider user is uniquely identified to the computer via a user menu which includes an item for receiving a one-way encrypted password from the user to identify the user as a medical service provider user prior to displaying the activities menu for a medical service provider user role, including the request for pre-approval of a medical claim; and

while the patient remains in the office of the medical service provider, performing a pre-approval process in accordance with the request comprising;

receiving, by the computer, the request for pre-approval via the electronic medium;

analyzing, by the computer, the request for pre-approval in order to determine whether the request for pre-approval is in condition for approval, the analyzing including one or more of checking eligibility of the patient in a medical plan offered by a medical plan provider, comparing a medical claim history of the patient to the medical claim in order to check for a duplicate claim, comparing a contract between the medical service provider and the medical plan provider to the medical procedure to which the medical claim pertains, and comparing a medical benefit of the patient in the medical plan to the medical procedure to which the medical claim pertains, wherein comparing a medical benefit of the patient is performed in accordance with multiple inter-related menus including a benefits menu coupled to a revenue code menu, a service code menu and an accumulator menu for aggregating multiple accumulator items in the benefits menu;

determining that the request for pre-approval is not in condition for approval;

rejecting, by the computer, the request for pre-approval;

identifying, by the computer, at least one reason the request for pre-approval was rejected; and

transmitting, by the computer, a message containing information regarding the rejection of the request for pre-approval and the at least one reason for rejection to the medical service provider via the electronic medium in order to enable the creation of an altered request for pre-approval on behalf of the patient comprising the request for pre-approval as altered according to the information;

receiving, by the computer, the altered request for pre-approval;

analyzing, by the computer, the altered request for pre-approval in order to determine whether the altered request for pre-approval is in condition for approval, the analyzing including one or more of checking eligibility of the patient in a medical plan offered by a medical plan provider, comparing a medical claim history of the patient to the medical claim in order to check for a duplicate claim, comparing a contract between the medical service provider and the medical plan provider to the medical procedure to which the medical claim pertains, and comparing a medical benefit of the patient in the medical plan to the medical procedure to which the medical claim pertains, wherein comparing a medical benefit of the patient is performed in accordance with multiple inter-related menus including a benefits menu coupled to a revenue code menu, a service code menu and an accumulator menu for aggregating multiple accumulator items in the benefits menu;

approving the altered request for pre-approval,

receiving and approving, by the computer, an altered medical claim associated with the altered request for pre-approval;

informing, by the computer, the medical service provider via the electronic medium that the altered medical claim associated with the altered request for pre-approval has been approved;

determining a monetary value to the medical service provider of the medical procedure to which the altered medical claim pertains;

determining a monetary value to the patient of the medical procedure to which the altered medical claim pertains;

wherein determining the monetary values to the medical service provider and the patient of the medical procedure includes

accessing a database storing a plurality of requirements and conditions for multiple claims, wherein the altered medical claim meets at least some of the requirements and conditions for a first and second of the multiple claims,

scoring each of the first and second of the multiple claims in accordance with predetermined criteria related to each of the requirements and conditions of each of the first and second of the multiple claims the altered medical claim meets;

determining the monetary values based on scoring results; and

informing, by the computer, the medical service provider of a monetary value of the medical procedure to the medical service provider and to the patient.

6. The method of claim 5 wherein:

receiving the request for pre-approval and performing the pre-approval process occur within a three-minute period of time.

7. The method of claim 5 further comprising:

while the patient remains in the office of the medical service provider, verifying correctness of claim information in the altered medical claim.

8. The method of claim 5, further comprising:

electronically transferring the monetary value for the medical procedure to the medical service provider to an account of the medical service provider.

9. The method of claim 8 wherein:

electronically transferring the monetary value for the medical procedure to the medical service provider occurs within five days of receiving the altered medical claim and occurs absent manual intervention.

10. The method of claim 5 wherein:

the electronic medium comprises the Internet.