Healthcare financial data and clinical information processing system

• US 20030195771A1
• Filed: 09/24/2002
• Published: 10/16/2003
• Est. Priority Date: 04/16/2002
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Siemens Medical Solutions USA Incorporated (Siemens AG)
• Inventors: Lucas, Brian, Klassen, David Hiebert Sr., Long, Greg, Fitzgerald, David, Hunter, John
• Granted Patent: US 7,797,172 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• 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 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

A patient claim data processing system responds to and initiates clinical events and attains early accurate claim data during a patient healthcare encounter cycle to support prompt claim data validation and editing both for individual claim elements and for a completed claim to improve claim accuracy prior to claim submission to a payer. The system submits accurate claims to payers and receives remittance advice from payers and applies rules to the advice. A system processes financial data related to provision of healthcare to a patient in response to clinical events. The system includes an interface processor for receiving a message identifying an event and a related change in healthcare data concerning a patient and also includes a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient. A rules processor initiates application of a rule derived from the rules source to process financial data concerning provision of the individual service to the patient in response to receiving the message identifying the event. A result processor initiates an action in response to a result derived by the application of the rule to process the financial data. The rules processor also validates the financial data complies with the rule.

Claims

1. A system for processing financial data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving a message identifying an event and a related change in healthcare data concerning a patient;

a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient;

a rules processor for initiating application of a rule derived from said rules source to process financial data concerning provision of said individual service to said patient in response to receiving said message identifying said event; and

a result processor for initiating an action in response to a result derived by said application of said rule to process said financial data.

2. A method according to claim 1, wherein

said event comprises at least one of, (a) generation of a record associated with provision of a service to patient, (b) generation of a billing related record for provision of a service to patient, (c) generation of an indication of occurrence of provision of healthcare to a patient by an operating process, (d) generation of an indication of occurrence of provision of healthcare to a patient by patient monitoring equipment and (e) generation of an indication of occurrence of provision of healthcare to a patient by a medical device.

3. A system according to claim 1, wherein

said result processor, in response to said derived result, initiates addition of a task to a worklist of a healthcare worker, said task comprising review of data derived as said result of said application of said rule to process said financial data.

4. A system according to claim 3, wherein

said data for review comprises at least one of, (a) a notification of denial of a particular treatment for a patient, (b) a notification of a requirement for a waiver to be provided for qualification of a treatment for reimbursement and (c) a result of processing a trial claim for reimbursement for a particular treatment for a patient.

5. A system according to claim 1, wherein

said rules processor initiates application of rules derived from said rules source to process data concerning provision of said individual service to said patient by examining a billing record to determine if no payment has been made by a healthcare payer organization within a predetermined period in response to receiving said message identifying said event, and

said result processor, in response to said derived result, initiates actions to collect said overdue payment.

6. A system according to claim 1, wherein

said result processor, in response to said derived result, initiates at least one of, (a) linking a record of a pre-admission test to a record of a surgical procedure, (b) linking a record of a same day surgery procedure to a record of an inpatient encounter, (c) linking a record identifying a mother to a record associated with a newborn baby and (d) linking a record of an outpatient procedure to an inpatient encounter occurring on the same day.

7. A system according to claim 1, wherein

said result processor, in response to said derived result, initiates deletion of a task from a worklist of a healthcare worker.

8. A system according to claim 1, wherein

said result processor, in response to said derived result, initiates addition of a task to a worklist for medical equipment.

9. A system according to claim 1, wherein

said characteristics associated with reimbursement to a provider for provision of an individual service to a patient, comprise at least one of, (a) an expected reimbursement amount for provision of an individual service to a patient, (b) an effective benefit period for said reimbursement, (c) contract constraints for said reimbursement, (d) an indication said provision of said individual service to said patient qualifies for reimbursement under a particular insurance plan and (e) an indication said provision of said individual service to said patient is linked to provision of other services to said patient.

10. A system according to claim 1, wherein

a rule comprises a procedure for determining claim elements comply with predetermined requirements including at least one of, (a) health plan reimbursement conditions, (b) health plan format requirements, (c) a reimbursement formula, (d) reimbursement constraints and (e) reimbursement computation procedure.

11. A system according to claim 10, wherein

said claim elements comprise at least one of, (i) a portion of a claim, (ii) a complete claim, (iii) individual records of a claim and (iv) record data associated with an individual patient encounter with a healthcare service provider.

12. A system according to claim 1, wherein

a rule includes a test for assigning a status of True or False as said result in response to said application of said rule to process said financial data.

13. A system according to claim 1, wherein

said rules processor validates said financial data complies with said rule.

14. A system according to claim 1, wherein

said received message identifying an event is received from a clinical information system and is generated in response to performance of a healthcare associated task by at least one of, (a) a healthcare worker and (b) medical equipment.

15. A system according to claim 1, wherein

said rules processor selects said rule derived from said rules source based on said identified event using a database linking an individual event with at least one corresponding rule.

16. A system for processing claim data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

a source of rules for validating claim data elements concerning provision of individual services to a patient;

a rules processor for initiating application of rules derived from said rules source to individually validate different claim data elements concerning provision of corresponding different individual services to a patient in response to receiving said messages identifying said events; and

a result processor for initiating an action in response to a result derived by said application of said rules to individually validate different claim data elements.

17. A system according to claim 16, wherein

said rules processor validates a claim data element for provision of an individual service to a patient by determining at least one of, (a) said claim data element is reimbursable under a healthcare insurance plan, (b) said claim data element is determined to meet medical necessity requirements under a healthcare insurance plan, (c) an expected reimbursement amount for said provision of said service and (c) a rule waiver is required for reimbursement to be allowed.

18. A system according to claim 16, wherein

said rules processor collates validated claim data elements to produce a claim for provision of a plurality of services to said patient.

19. A system according to claim 18, wherein

said rules processor validates a plurality of claim data elements comply with reimbursement rules requiring combined reimbursement for provision of different services.

20. A system according to claim 18, wherein

said rules processor submits said validated collated claim data elements to a payer, in response to successful validation.

21. A system according to claim 16, wherein

a claim data element comprises financial data together with patient and clinical service identification data for provision of a specific service to a patient, and said claim data element being subject to validation by a rule to determine at least one of (a) compliance with information sufficiency requirements and (b) compliance with format requirements.

22. A system according to claim 16, wherein

said result processor prompts a user with a candidate alternative service in response to unsuccessful validation of a claim data element for provision of a particular service.

23. A system for processing claim data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

a source of rules for validating claim data elements concerning provision of individual services to a patient;

a rules processor for initiating application of rules derived from said rules source to identify claim data element deficiencies in response to receiving said messages identifying said events; and

a result processor for initiating an action in response to a result derived by said application of said rules to individually validate different claim data elements.

24. A system according to claim 23, wherein

said rules processor corrects identified claim element deficiencies in response to applying said rules.

25. A method for processing financial data related to patient healthcare in response to clinical events, comprising the steps of:

receiving a message identifying an event and a related change in healthcare data concerning a patient;

initiating application of a rule derived from a rules source to process financial data concerning provision of an individual service to said patient in response to receiving said message identifying said event, said rules being usable for determining characteristics associated with reimbursement for provision of an individual service to a patient; and

initiating an action in response to a result derived by said application of said rule to process said financial data.

26. A method for processing claim data related to patient healthcare in response to clinical events, comprising the steps of:

receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

initiating application of rules derived from a rules source to individually validate different claim data elements concerning provision of corresponding different individual services to a patient in response to receiving said messages identifying said events, said rules being usable for validating claim data elements concerning provision of individual services to said patient; and

initiating an action in response to a result derived by said application of said rules to individually validate different claim data elements.

27. A method for processing claim data related to patient healthcare in response to clinical events, comprising the steps of:

receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

initiating application of rules derived from a rules source to identify claim data element deficiencies in response to receiving said messages identifying said events, said rules being usable for validating claim data elements concerning provision of individual services to said patient; and

initiating an action in response to a result derived by said application of said rules to individually validate different claim data elements.