System and method for calculating estimated payment based on partial coding data

• US 10,296,976 B1
• Filed: 09/23/2011
• Issued: 05/21/2019
• Est. Priority Date: 09/23/2011
• 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: Hoerle, Dale, Nelson, Debra Romig, Jones, Rachael Nadesda Mcalla
• Primary Examiner(s): Burgess, Joseph D
• Application Number:
  US13/242,954
• Time in Patent Office: 2,797 Days
• Field of Search: None
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Processes for estimating payment on a claim for services rendered are described. The process includes formatting data related to a medical service to be rendered to a patient in a mock claim, applying pricing rules that are unique to an agreement between payer entity and a provider of the service; and determining an estimated payment for the medical service to be paid by the payer to the provider after the medical service has been rendered to the patient.

Claims

1. A process for tracking and calculating payment due for a completed patient episode on an on-going basis as individual services are provided as part of the patient episode and prior to submission of one or more actual claims to one or more payers for adjudication and determination of one or more payments due to one or more providers related to the patient episode for services rendered comprising:

accessing by a patient episode tracker application, on an on-going basis, via multiple web services calls, individual services data stored in a master charge list database on a provider network, wherein the individual services data includes data related to multiple patients, multiple patient episodes and multiple providers;

determining by the patient episode tracker that the accessed individual services data includes a first indicator of a first at least one medical service to be rendered to a first patient as part of a first patient episode and a second indicator identifying a first payer entity which has agreed to pay for the first at least one medical service as part of the one or more payments due related to a completed first patient episode, further wherein the first patient episode is identified by a first unique code;

receiving by a mock claim generator application at a first predetermined time a first data set from the patient episode tracker application including the first indicator and the second indicator, said first data set not including at least some additional data required to adjudicate an actual claim for the completed first patient episode including the first at least one medical service as part of the one or more payments due related to the completed first patient episode;

formatting by the mock claim generator application the first data set into an actual electronic claim format to generate a first mock claim, the actual electronic claim format being unique to the payer entity, wherein the formatting further includes adding one or more payer contract identifying codes to the first mock claim in accordance with the received second indicator and submitting the first mock claim at the first predetermined time to a pricing engine;

retrieving by the pricing engine pricing rules based on the one or more payer contract identifying codes, wherein the pricing rules are unique to an agreement between the payer entity and the provider of the first patient episode;

applying by the pricing engine the pricing rules to the first mock claim to calculate a first estimated payment for the completed first patient episode based on the first at least one medical service to be paid by the payer entity to the provider after completion of the first patient episode, including performance of all individual services provided as part of the first patient episode and submission of an actual claim for the completed first patient episode for adjudication;

receiving the calculated first estimated payment via a web services call at the provider network and storing the first estimated payment for the first patient episode in an accounts receivable database in accordance with the first unique code;

determining by the patient episode tracker that the accessed individual services data includes the first indicator, the second indicator and at least a third indicator related to a second at least one medical service to be rendered to the patient provided as part of the first patient episode;

receiving by the mock claim generator application at a second predetermined time a second data set from the patient episode tracker application including the first indicator, the second indicator and the third indicator, said second data set not including at least some data required to adjudicate an actual claim for the completed first patient episode including the first and second at least one medical services as part of the one or more payments due related to the completed first patient episode, wherein providing the second data set to the mock claim generator application at the second predetermined time is triggered by the accessed third indicator related to a second at least one medical service to be rendered to the patient;

formatting by the mock claim generator application the second data set into a second mock claim using the actual electronic claim format, wherein the formatting further includes adding one or more payer contract identifying codes to the first mock claim in accordance with the received second indicator and submitting the second mock claim at the second predetermined time to the pricing engine;

retrieving by the pricing engine pricing rules based on the one or more payer contract identifying codes;

applying by the pricing engine the pricing rules to the second mock claim to calculate a second estimated payment for the completed first patient episode based on the first at least one medical service and the second at least one medical service to be paid by the payer entity to the provider after completion of the first patient episode, including performance of all individual services provided as part of the first patient episode and submission of an actual claim for the completed first patient episode for adjudication;

receiving the calculated second estimated payment via a web services call at the provider network, comparing the second estimated payment with the first estimated payment and storing the second estimated payment for the first patient episode in the accounts receivable database in accordance with the first unique code when the second estimated payment is not equal to the first estimated payment;

determining by the patient episode tracker that the accessed individual services data includes the first indicator, the second indicator, the third indicator related and at least one additional indicator related to a third at least one medical service rendered to the patient as part of the completed first patient episode, wherein the at least one additional indicator is informative of a completed first patient episode;

receiving by the pricing engine an actual claim from the patient episode tracker in the actual electronic claim format for the completed first patient episode for adjudication at a third predetermined time, wherein the actual claim includes a third data set including the first indicator, the second indicator, the third indicator and the at least one additional indicator related to a third at least one medical service rendered to the patient as part of the completed first patient episode, wherein providing the third data set at the third predetermined time is triggered by the accessed at least one additional indicator related to the third at least one medical service to be rendered to the patient;

retrieving pricing rules to adjudicate the actual claim for the completed first patient episode based on the one or more payer contract identifying codes identified in accordance with the second indicator

applying by the pricing engine the pricing rules to the actual claim to calculate final payment for the completed first patient episode to be paid by the payer entity to the provider; and

receiving the calculated final payment via a web services call at the provider network, comparing the final payment with the second estimated payment and storing the final payment for the first patient episode in the accounts receivable database in accordance with the first unique code when the final payment is not equal to the second estimated payment.

2. The process according to claim 1, wherein the first indicator, third indicator and the at least one additional indicator are selected from the group consisting of a diagnosis code, a diagnosis-related group (DRG) code, ambulatory payment classification (APC), a revenue code or a procedure code.

3. The process according to claim 1, wherein the actual claim format is selected from the group consisting of Uniform Billing Form UB-04, CMS-1500, the Health Care Finance Administration Billing Form Number 1500 (HCFA 1500) and ANSI X.12 5010 form.

4. The process according to claim 1, wherein the second indicator is a patient identifier (ID).

5. The process according to claim 1, wherein the first estimated payment at the first predetermined time is the same as the second estimated payment at the second predetermined time, but the final payment at the third predetermined time is different.

6. The process according to claim 1, wherein the first estimated payment at the first predetermined time, the second estimated payment at the second predetermined time and the final payment at the third predetermined time are the same.