System and method for secure highway for real-time preadjudication and payment of medical claims

• US 20030149594A1
• Filed: 04/15/2002
• Published: 08/07/2003
• Est. Priority Date: 04/13/2001
• Status: Abandoned Application

• Current Assignee: MDWerks, Inc.
• Original Assignee: MDWerks, Inc.
• Inventors: Beazley, Donald E., Nudel, Jacob
• Application Number:
  US10/121,615
• Publication Number:
  US 20030149594A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/04 Payment circuits
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 20/14 specially adapted for billing systems
• CPC Class Codes: G06Q 20/4016 involving fraud or risk level assessment in transaction processing
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A system and method for real-time pre-adjudication, funding and payment of medical expenses to a Provider for a Claim, the Claim having a Payer, wherein a line of credit is established that is associated with the Claim. One variation of the system provides automated and optionally network-based assistance to Participants in the health industry. The Participants include: Providers, Payers, Funding Institution, Patients, Employers, and E-Market Exchanges. The method of the system includes: receiving a medical expenses Claim which is scrubbed; prior to adjudication of the Claim funding the Provider from a line of credit, with funding determined using risk analysis tools and utilizing a recorded security interest; collecting payment from the Payer via a secured environment; and repaying the line of credit from the collected Payer payment with follow-up reporting and record keeping.

Claims

1. A method for pre-adjudication, funding, and payment of medical expenses to a Provider for a medical expenses claim, the claim having an associated amount, wherein a line of credit is established, the method comprising:

receiving the claim from the Provider;

prior to adjudication of the claim, funding a portion of the claim to the Provider from the line of credit; and

collecting the amount of the claim from a Payer.

2. The method of claim 1, further comprising:

repaying the line of credit from the collected amount.

3. The method of claim 1, wherein the Provider is selected from a group consisting of a physician or a hospital.

4. The method of claim 1, wherein the Payer is an insurance company.

5. The method of claim 1, wherein the line of credit is established by a financial institution.

6. The method of claim 1, further comprising:

receiving a claim from the Provider; and

scrubbing the claim.

7. The method of claim 6, wherein scrubbing the claim comprises:

validating data for the claim.

8. The method of claim 6, wherein scrubbing the claim further comprises:

comparing the data to Rulesets.

9. The method of claim 6, wherein checking the claim comprises:

passing the claim payment request through a Verified Enhanced Term Sheet (VETS);

comparing data for the claim to Rulesets; and

submitting a claim payment request to a Financial Institution for approval.

10. The method of claim 9, wherein the VETS comprises a criteria and funding management process.

11. The method of claim 1, further comprising:

taking a secured interest in the claim.

12. The method of claim 1, further comprising:

completing a risk analysis of the claim.

21. The method of claim 1, wherein:

a claim is received from the Provider;

the claim is checked; and

if the claim is approved, the Provider is paid with the line of credit;

if the claim is denied, the Provider is sent a notice of denial.

22. The method of claim 21, wherein checking the claim further comprises:

passing the claim payment request through a VETS Financial Institution choice;

approving Rulesets; and

submitting the claim to the Financial Institution for approval.

13. A system for pre-adjudication and payment of medical expenses to a Provider for a medical expenses claim, wherein a line of credit is established, the system comprising:

terminals coupled to a network for receiving and transmitting claim information for the Provider, a Payer, and a Financial Institution; and

a server coupled to the network for receiving and transmitting claim information;

wherein a claim is received from the Provider;

wherein, prior to adjudication of the claim, claim payment is provided to the Provider from the line of credit; and

wherein the amount of the claim payment is collected from a Payer.

14. The system of claim 13, wherein the line of credit is repaid from the collected Payer payment.

15. The system of claim 13, wherein the Provider is selected from a group consisting of a physician or a hospital.

16. The system of claim 13, wherein the Payer is an insurance company.

17. The system of claim 13, wherein the line of credit is established, used to pay the Provider, and repaid by a Financial Institution.

18. The system of claim 13, wherein:

a claim request is received from the Provider;

the claim request is scrubbed; and

approval or denial is sent to the Provider.

19. The system of claim 18, wherein the claim request is scrubbed by:

validating the data for the claim.

20. The system of claim 18, wherein scrubbing the claim further comprises:

comparing the data to Rulesets.

23. The system of claim 13, wherein the network is a Virtual Private Network.

24. The system of claim 13, wherein the network is an Internet.

25. The system of claim 13, further comprising a proxy server to manage traffic on the network.

26. The system of claim 13, further comprising a browser to allow users to view documents and access files and software.

27. The System of claim 13, further comprising interfaces to allow users to view documents and access files and software.

28. The System of claim 13, further comprising a call center coupled to the network to provide users support and answers for questions and problems the users have with the system.

29. The system of claim 13, further providing a clearing house coupled to the network.

30. The system of claim 13, further comprising a firewall coupled to the network to protect the network against external threats.

31. The system of claim 13, further comprising coupling to couple various components to the network.

32. The system of claim 13, comprising terminals coupled to the network.

33. The system of claim 13, comprising servers coupled to the network.