Account prioritization for patient access workflow

• US 10,354,211 B1
• Filed: 02/19/2013
• Issued: 07/16/2019
• Est. Priority Date: 02/18/2012
• Status: Active Grant

• Current Assignee: Experian Health, Inc. (Experian plc)
• Original Assignee: Passport Health Communications (Experian plc)
• Inventors: Pilkington, Edmond Chase, Magee, Joseph M., Bright, Howard, Moreau, Michael Cohn, Mansfield, Lance Clifford
• Primary Examiner(s): Nguyen, Hiep V
• Application Number:
  US13/770,660
• Time in Patent Office: 2,338 Days
• Field of Search: None
• CPC Class Codes: G06Q 10/0633 Workflow analysis
• 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

Account prioritization for a patient access workflow is provided. The patient access workflow may be an exception-based integrated workflow. An indication of discrepant data, missing data, or input/user-interaction that may be needed for performance of a patient access workflow process for a patient account may be provided via alerts displayed in an integrated user interface. A prioritization engine may determine a priority score for a patient account based on various determining factors and weightings applied to each determining factor. The patient account may be placed in a queue of accounts needing to be cleared in order by priority score, such that when a user selects to receive a next account to clear, the account with the highest priority score may be provided to the user. Accordingly, a user may be able to address and resolve alerts to ensure patient access workflow processes are performed prior to a healthcare encounter.

Claims

1. A machine-implemented method using one or more computer hardware components to generate a user interface (UI) that includes a plurality of selectable controls comprising:

using the one or more computer hardware components to generate a queue of patient accounts that includes a data structure of prioritized patient accounts in the queue of patient accounts;

using the one or more computer hardware components as part of evaluating patient data of each patient account of the queue of patient accounts and third party data from at least one third party data system to identify issues to be resolved with each patient account;

using the one or more computer hardware components as part of flagging each patient account with alerts to identify additional steps needed to be completed for performing one or more processes of a patient access workflow for each issue identified;

using the one or more computer hardware components to generate a set of weighted factors to apply when calculating priority scores to automatically prioritize patient accounts in the queue of patient accounts to display in the UI including;

generating a first weighted factor for each patient account in the queue of patient accounts according to an amount of time until a healthcare encounter with a healthcare service provider;

generating a second weighted factor for each patient account in the queue of patient accounts according to an estimate of an amount of time to resolve each issue associated with the alerts for each patient account based in part on an estimate of an amount of time to process each of the one or more processes of the patient access workflow for each type of alert;

generating a third weighted factor for each patient account in the queue of patient accounts according to a cost of a service or procedure associated with each patient account;

generating a fourth weighted factor for each patient account in the queue of patient accounts according to a type of insurance network or plan associated with each patient account;

generating a fifth weighted factor for each patient account in the queue of patient accounts according to services or procedures scheduled for each patient account; and

generating a sixth weighted factor for each patient account in the queue of patient accounts according to identified discrepancies in each patient account;

using the one or more computer hardware components to calculate a priority score for each patient account of the queue of patient account according to the set of weighted factors that includes;

the first weighted factor, the second weighted factor, the third weighted factor, the fourth weighted factor, the fifth weighted factor, and the sixth weighted factor;

using the one or more computer hardware components to display a patient account having a highest priority score in the UI before displaying other patient accounts in the queue of patient accounts;

using the one or more computer hardware components to display the plurality of selectable controls with the UI including an alerts UI control, a demographics UI control, a coverage UI control, a medical necessity UI control, a pre-certification UI control, an estimate UI control, and a next UI control, wherein;

in response to selection of the alerts UI control, display an overview page in the UI for the patient account with the highest priority score from the queue according to the set of weighted factors, the overview page including;

one or more of a general alert display portion, a demographics alert display portion, a coverage alert display portion, a medical necessity alert display portion, a pre-certification alert display portion, and a claims alert display portion, and

one or more selectable alert UI elements displayed in one or more of the general alert display portion, the demographics alert display portion, the coverage alert display portion, the medical necessity alert display portion, the pre-certification alert display portion, and the claims alert display portion for the patient account with the highest priority score, and

in response to selection of a selectable alert UI element, display a UI page for a corresponding patient access workflow process associated with one or more demographics alerts, coverage alerts, medical necessity alerts, pre-certification alerts, and claims alerts;

in response to actuation of the next UI control that operates to display a next patient account in the UI having a next highest priority score according to the set of weighted factors, using the one or more computer hardware components to display the next patient account in the UI having the next highest priority score.

2. The method of claim 1, further comprising-receiving results from one or more automated patient access workflow processes including one or more of:

demographics information verification;

coverage information verification;

medical necessity validation;

pre-certification;

estimation;

financial clearance;

or

collections.

3. The method of claim 1, further comprising using the one or more computer hardware components to generate general alerts, demographics alerts, coverage alerts, medical necessity alerts, pre-certification alerts, and claims alerts in the UI, wherein the UI includes the selectable controls that operate to switch between pages that include the general alerts, demographics alerts, coverage alerts, medical necessity alerts, pre-certification alerts, and claims alerts in the UI for the patient account.

4. The method of claim 1, further comprising determining types of the alerts to be resolved to clear each patient account.

5. The method of claim 1, further comprising receiving a request for a next patient account and providing the next patient account with the next highest priority score for display in the UI.

6. The method of claim 1, wherein evaluating patient data and flagging each patient account occurs during one or more automated patient access workflow processes.

7. The method of claim 1, further comprising generating additional weighted factors to calculate the priority score for each patient account including:

a seventh weighted factor corresponding to whether each patient account is self-pay or has insurance coverage; and

an eighth weighted factor corresponding to which payer is providing insurance coverage for each patient account.

8. The method of claim 7, further comprising generating additional weighted factors including:

a ninth weighted factor corresponding to historical claim denials by the payer providing insurance coverage for the services or procedures scheduled for the healthcare encounter; and

a tenth weighted factor corresponding to statistical information linking a likelihood of non-payment associated with each patient account.

9. The method of claim 1, further comprising displaying the selectable alert UI elements in groups within the overview based on automated patient access workflow processes.

10. A system to generate a user interface (UI) that includes a plurality of selectable controls comprising:

one or more computer hardware components that include a processor, memory, a computer display, the UI, and a communication network;

one or more of automated patient workflow engines operable with the one or more computer hardware components in communication over the communication network with at least one third party data system and operable to evaluate patient data of each patient account against data stored by the at least one third party data system to identify issues to be resolved with each patient account and display alerts to identify additional steps needed to be completed for performing one or more processes of a patient access workflow to clear each patient account;

a prioritization engine operable with the one or more computer hardware components to;

generate a queue of patient accounts that includes a data structure of prioritized patient accounts in the queue of patient accounts;

generate a set of weighted factors to apply when calculating priority scores to automatically prioritize patient accounts in the queue of patient accounts according to the set of weighted factors such that a patient account having a highest priority score is displayed in the UI before other patient accounts in the queue of patient accounts, the prioritization engine to;

generate a first weighted factor for each patient account in the queue of patient accounts according to an amount of time until a healthcare encounter with a healthcare service provider;

generate a second weighted factor for each patient account in the queue of patient accounts according to an estimate of an amount of time to resolve each issue associated with the alerts for each patient account based in part on an estimate of an amount of time to process each of the one or more processes of the patient access workflow for each type of alert;

generate a third weighted factor for each patient account in the queue of patient accounts according to a cost of a service or procedure associated with each patient account;

generate a fourth weighted factor for each patient account in the queue of patient accounts according to a type of insurance network or plan associated with each patient account;

generate a fifth weighted factor for each patient account in the queue of patient accounts according to services or procedures scheduled for each patient account; and

generate a sixth weighted factor for each patient account in the queue of patient accounts according to identified discrepancies in each patient account;

calculate a priority score for each patient account of the queue of patient accounts according to the set of weighted factors-that includes;

the first weighted factor, the second weighted factor, the third weighted factor, the fourth weighted factor, the fifth weighted factor, and the sixth weighted factor; and

order each patient account within the queue of patient accounts based on a corresponding priority score; and

the UI operable with the one or more computer hardware components to display

the plurality of selectable controls including an alerts UI control, a demographics UI control, a coverage UI control, a medical necessity UI control, a pre-certification UI control, an estimate UI control, and a next UI control, wherein;

in response to selection of the alerts UI control, display an overview page in the UI for the patient account with the highest priority score from the queue according to the set of weighted factors, the overview page including;

one or more of a general alert display portion, a demographics alert display portion, a coverage alert display portion, a medical necessity alert display portion, a pre-certification alert display portion, and a claims alert display portion, and

one or more selectable alert UI elements displayed in one or more of the general alert display portion, the demographics alert display portion, the coverage alert display portion, the medical necessity alert display portion, the pre-certification alert display portion, and the claims alert display portion for the patient account with the highest priority score, and

in response to selection of a selectable alert UI element, display a UI page for a corresponding patient access workflow process associated with one or more demographics alerts, coverage alerts, medical necessity alerts, pre-certification alerts, and claims alerts; and

in response to actuation of the next UI control that operates to display a next patient account in the UI having a next highest priority score according to the set of weighted factors, the UI displays the next patient account having the next highest priority score.

11. The system of claim 10, wherein the one or more automated patient workflow engines use one or more of:

alerts data;

demographics information verification data;

coverage information verification data;

medical necessity validation data;

pre-certification data;

estimate data;

financial clearance data;

or

collections data.

12. The system of claim 10, wherein the weighted factors are based on historical data.

13. The system of claim 10, further to calculate the priority score for each patient account according to:

a seventh weighted factor corresponding to whether each patient account is self-pay or has insurance coverage; and

an eighth weighted factor corresponding to a specific payer providing insurance for each patient account.

14. The system of claim 10, further operable to receive a request for a next patient account and provide the next patient account with a next highest priority score.

15. The system of claim 10, wherein selection of a selectable alert UI element operates to display at least one of:

a page from the one or more automated patient workflow engine that set the associated alert containing the corresponding patient data and allow the issue to be addressed; and

additional information about the issue associated with the associated alert.

16. A non-transitory computer readable medium containing executable instructions which, when executed, generate a user interface (UI) that includes a plurality of selectable controls and:

use one or more computer hardware components to generate a queue of patient accounts that includes a data structure of prioritized patient accounts in the queue of patient accounts;

use one or more computer hardware components to evaluate patient data of each patient account of the queue of patient accounts and third party data from at least one third party data system to identify issues to be resolved with each patient account;

use the one or more computer hardware components to flag each patient account with alerts to identify additional steps needed to be completed for performing one or more processes of a patient access workflow for each issue identified;

use the one or more computer hardware components to generate a set of weighted factors to apply when calculating priority scores to automatically prioritize patient accounts in the queue of patient accounts to display in the UI including;

generating a first weighted factor for each patient account in the queue of patient accounts according to an amount of time until a healthcare encounter with a healthcare service provider;

generating a second weighted factor for each patient account in the queue of patient accounts according to an estimate of an amount of time to resolve each issue associated with the alerts for each patient account based in part on an estimate of an amount of time to process each of the one or more processes of the patient access workflow for each type of alert;

generating a third weighted factor for each patient account in the queue of patient accounts according to a cost of a service or procedure associated with each patient account;

generating a fourth weighted factor for each patient account in the queue of patient accounts according to a type of insurance network or plan associated with each patient account;

generating a fifth weighted factor for each patient account in the queue of patient accounts according to services or procedures scheduled for each patient account; and

generating a sixth weighted factor for each patient account in the queue of patient accounts according to identified discrepancies in each patient account;

use the one or more computer hardware components to calculate a priority score for each patient account according to the set of weighted factors that includes;

the first weighted factor, the second weighted factor, the third weighted factor, the fourth weighted factor, the fifth weighted factor, and the sixth weighted factor;

use the one or more computer hardware components to order each patient account within the queue of patient accounts based on the priority score;

use the one or more computer hardware components to display a patient account having a highest priority score in the UI before displaying other patient accounts in the queue of patient accounts;

use the one or more computer hardware components to display selectable controls with the UI including an alerts UI control, a demographics UI control, a coverage UI control, a medical necessity UI control, a pre-certification UI control, an estimate UI control, and a next UI control, wherein;

in response to selection of the alerts UI control, display an overview page in the UI for the patient account with the highest priority score from the queue according to the set of weighted factors, the overview page including;

one or more of a general alert display portion, a demographics alert display portion, a coverage alert display portion, a medical necessity alert display portion, a pre-certification alert display portion, and a claims alert display portion, and

one or more selectable alert UI elements displayed in one or more of the general alert display portion, the demographics alert display portion, the coverage alert display portion, the medical necessity alert display portion, the pre-certification alert display portion, and the claims alert display portion for the patient account with the highest priority score, and

in response to selection of a selectable alert UI element, display a UI page for a corresponding patient access workflow process associated with one or more demographics alerts, coverage alerts, medical necessity alerts, pre-certification alerts, and claims alerts;

and

in response to actuation of the next UI control that operates to display a next patient account in the UI having a next highest priority score according to the set of weighted factors, use the one or more computer hardware components to display the next patient account in the UI having the next highest priority score.

17. The non-transitory computer readable medium of claim 16, wherein determining a priority score for each patient account further comprises generating:

a seventh weighted factor corresponding to whether the patient account is self-pay or has insurance coverage; and

an eighth weighted factor corresponding to a specific payer providing insurance for the patient account.