Exception-based integrated patient access workflow

• US 10,410,305 B1
• Filed: 02/19/2013
• Issued: 09/10/2019
• Est. Priority Date: 02/18/2012
• Status: Active Grant

• Current Assignee: Experian Health, Inc. (Experian plc)
• Original Assignee: Experian Health, Inc. (Experian plc)
• Inventors: Pilkington, Edmond Chase, Magee, III, Joseph M., Bright, Howard, Moreau, Michael, Mansfield, Lance, Padgett, Marcus
• Primary Examiner(s): Paulson, Sheetal R
• Application Number:
  US13/770,587
• Time in Patent Office: 2,394 Days
• 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

An exception-based integrated patient access workflow via a single user interface is provided. When patient data associated with a healthcare encounter is received, various rules may be applied to cross-check the received data with other stored and received data to ensure correct patient data and to ensure accurate information for downstream patient access workflow processes. An indication of discrepant data, missing data, or input/user-interaction that may be needed for performance of a patient access workflow process may be provided. The indication may be provided via alerts displayed in an integrated user interface. 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 system to transform raw information into actionable intelligence and integrate workflows via an integrated user interface (UI) comprising:

a computer processor; and

a computer storage device that stores instructions that, when executed by the computer processor, integrates outputs of a plurality of workflow engines to generate the integrated UI to display and enable resolution of generated alerts via the integrated UI according to the outputs of the plurality of workflow engines, the instructions to;

enable a display of a first selectable control with the integrated UI that, when selected, operates to display a demographics UI display as part of the integrated UI;

in response to selection of the first selectable control of the integrated UI, display the demographics UI display with data provided by a first workflow engine comprising a demographic information verification engine, wherein the demographics UI display displays alerts with patient data that differs from the demographic data stored in one or more third party data sources and marks conflicting demographic data provided by the one or more third party data sources;

enable a display of a second selectable control with the integrated UI that, when selected, operates to display a coverage UI display as part of the integrated UI;

in response to selection of the second selectable control of the integrated UI, display the coverage UI display with data provided by a second workflow engine comprising a coverage information verification engine, wherein the coverage UI display displays coverage verification alerts for coverage issues identified between the patient data and coverage information received from the one or more third party data sources;

enable a display of a third selectable control with the integrated UI that, when selected, operates to display an alert overview UI display as part of the integrated UI; and

in response to selection of the third selectable control of the integrated UI, display the alert overview UI display with alert data provided by a third workflow engine comprising an alerts engine, the alert overview UI display including an alert status UI display that displays resolved and/or unresolved alerts with alert details that include a type of alert, a current alert status, and an alert category, wherein

the demographic information verification engine outputs the data for the demographics UI display of the integrated UI after cross-matching the patient data with the demographic data stored in the one or more third party data sources to determine if any demographic data is missing from the patient data and that the demographic data in the patient data is consistent with the demographic data stored in the one or more third party data sources,

the coverage information verification engine outputs the data for the coverage UI display of the integrated UI after performing a query for coverages claimed by a patient or guarantor corresponding with the patient data and after cross-matching the patient data with insurance coverage data stored in the one or more third party data sources to determine if the coverage data is missing from the patient data and that the coverage data in the patient data is consistent with the coverage data stored in the one or more third party data sources, and

the alerts engine outputs the alert data for the alert overview UI display and one or more of the demographics UI display and the coverage UI display and generates one or more displayable alerts for display in the alert overview UI display and in one or more of the demographics UI display and the coverage UI display corresponding to the alert data affecting one or more downstream patient access workflow processes that depend on accurate data.

2. The system of claim 1, further comprising a pre-certification engine to identify procedures that require pre-certification according to the coverage data, wherein the alerts engine generates general alerts, demographics alerts, coverage alerts, medical necessity alerts, pre-certification alerts, and claims alerts.

3. The system of claim 2, further to generate displayable alerts based on outputs from:

the demographic information verification engine;

the coverage information verification engine;

a medical necessity validation engine;

a pre-certification engine;

an estimate engine;

a financial clearance engine; and

a collections engine.

4. The system of claim 2, further comprising:

a data store, wherein the system receives input in response to a displayed alert via the integrated UI, updates an alert status for the displayed alert in response to the received input, and stores the received input and the updated alert status in the data store.

5. The system of claim 1, further to generate alerts associated with:

medical necessity validation;

pre-certification;

estimation;

financial clearance;

or

collections.

6. The system of claim 5, further to generate an alert associated with a patient access workflow process requiring a resolving input.

7. The system of claim 6, further to display a selectable alert icon for each alert, wherein selection of the alert icon provides a display of a description of the resolving input that resolves the alert associated with a corresponding patient access workflow process, wherein the system updates and stores a status of the alert after the resolving input.

8. The system of claim 6, further to determine if a patient access workflow process requires a resolving input comprising a selected procedure or a diagnosis.

9. The system of claim 1, further to display a selectable alert icon for each alert, wherein selection of the selectable alert icon displays a description of the missing or inconsistent demographic or coverage data.

10. The system of claim 1, further to resolve alerts associated with:

the demographic information verification engine;

the coverage information verification engine;

a medical necessity validation engine;

a pre-certification engine;

an estimate engine;

a financial clearance engine; and

a collections engine.

11. The system of claim 1, to access one or more downstream patient access workflow processes that comprise one or more of:

medical necessity validation;

pre-certification;

estimation;

financial clearance;

or

collections.

12. The system of claim 11, further operable to:

determine if user input is required for performing one or more of the one or more downstream patient access workflow processes; and

if user input is required for performing a downstream patient access workflow process, provide an alert associated with the patient access workflow process requiring user input.

13. The system of claim 12, to display a selectable alert icon associated with a patient access workflow process, wherein selection of the selectable alert icon provides a display of a description of resolving input.

14. A non-transitory computer readable medium containing computer executable instructions which, when executed, transform raw information into actionable intelligence and integrate workflows via an integrated UI by:

enabling a display of a first selectable control that, when selected, operates to display a demographics UI display as part of the integrated UI;

in response to selection of the first selectable control of the integrated UI, displaying the demographics UI display with data provided by a first workflow engine comprising a demographic information verification engine, wherein the demographics UI display displays alerts with patient data that differs from the demographic data stored in one or more third party data sources and marks conflicting demographic data provided by the one or more third party data sources;

enabling a display of a second selectable control that, when selected, accesses a selectable coverage UI display;

in response to selection of the second selectable control of the integrated UI, displaying the coverage UI display with data provided by a second workflow engine comprising a coverage information verification engine, wherein the coverage UI display displays coverage verification alerts for coverage issues identified between the patient data and coverage information received from the one or more third party data sources;

enabling a display of a third selectable control that, when selected, operates to display an alert overview UI display as part of the integrated UI; and

in response to selection of the third selectable control of the integrated UI, displaying the alert overview UI display with alert data provided by a third workflow engine comprising an alerts engine including an alert status UI display that displays resolved and/or unresolved alerts with alert details that include a type of alert, a current alert status, and an alert category, wherein

the demographic information verification engine outputs the data for the demographics UI display of the integrated UI after cross-matching the patient data with the demographic data stored in one or more data third party sources to determine if any demographic data is missing from the patient data and that the demographic data in the patient data is consistent with the demographic data stored in the one or more third party data sources,

the coverage information verification engine outputs the data for the coverage UI display of the integrated UI after performing a query for coverages claimed by a patient or guarantor corresponding with the patient data and after cross-matching the patient data with the insurance coverage data stored in the one or more third party data sources to determine if the coverage data is missing from the patient data and that the coverage data in the patient data is consistent with the coverage data stored in the one or more third party data sources, and

the alerts engine outputs the alert data for the alert overview UI display and one or more of the demographics UI display and the coverage UI display and generates one or more displayable alerts for display in the alert overview UI display and in one or more of the demographics UI display and the coverage UI display corresponding to the alert data affecting one or more downstream patient access workflow processes that depend on accurate data.

15. The computer readable medium of claim 14, further to:

provide access to;

the demographic information verification engine;

the coverage information verification engine;

a medical necessity validation engine;

a pre-certification engine;

an estimate engine;

a financial clearance engine; and

a collections engine.

16. The computer readable medium of claim 14, further to:

receive, via the integrated UI, input in response to an alert;

determine if the input resolves the alert; and

if the input resolves the alert;

update an alert status for the alert; and

store the input and updated alert status in a data store.