Pharmacy automated accounts receivable system and methods

• US 20040054685A1
• Filed: 07/01/2003
• Published: 03/18/2004
• Est. Priority Date: 07/01/2002
• Status: Active Grant

• Current Assignee: Walgreen Co. (Walgreens Boots Alliance Incorporated)
• Original Assignee: Walgreen Corporation (Walgreens Boots Alliance Incorporated)
• Inventors: Addante, Steve, Rahn, Nancy
• Granted Patent: US 7,685,006 B2
• Time in Patent Office: Days
• US Class Current: 707/102
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A Pharmacy Automated Accounts Receivable (PAR) System and Methods allows a pharmacy drug store chain to manage, track, and reconcile third party payor receivables associated with prescription transactions. The PAR system obtains and uses data types including, but not limited to, prescription claim data, third party deposit data, third party payor data, and remittance advice data. The data obtained is configured into a PAR database to form PAR data that is used for automatically reconciling third party payor receivables associated with prescription transactions.

Claims

1. A method for reconciling third party payor receivables with a set of prescription transactions comprising the steps of:

obtaining prescription claim data associated with the set of prescription transactions, each of the set of prescription transactions corresponding to a prescription claim;

obtaining third party deposit data associated with the set of prescription transactions;

obtaining third party payor data associated with the set of prescription transactions;

obtaining remittance advice associated with the set of prescription transactions, the remittance advice comprising a plurality of remittance advice line items, each remittance advice line item associated with one of the prescription transactions of the set of prescription transactions;

configuring the prescription claim data, the third party deposit data, the third party payor data, and the remittance advice into a pharmacy automated accounts receivable system (PARS) database to form PARS data;

automatically reconciling third party deposit data,

wherein a failed reconciliation attempt automatically facilitates at least one process of automatic and manual reconciliation.

2. The method of claim 1, wherein the step of configuring the data results in generating a plurality of user-interactive graphical displays based on the PARS data.

3. The method of claim 2, enabling adjustments to the data in the PARS database via the plurality of user-interactive graphic display screens.

4. The method of claim 3, wherein adjustments to the data in the PARS database facilitate reconciliation of third party payor receivables.

5. The method of claim 1, wherein the step of automatically reconciling third party payor receivables includes the step of automatically identifying prescription transactions representing a need for manual reconciliation by a PARS user.

6. The method of claim 1, wherein the manual reconciliation process is one which attempts to match remittance advice batches and/or sub-batches to deposit batches and/or sub-batches comprising the steps of:

(a) selecting a criteria on which to base a work queue via a system user-interactive graphic display screen;

(b) building the work queue based on the selected criteria;

(c) selecting an available unmatched remittance advice batch or sub-batch line item displayed on the work queue;

(d) selecting an unmatched deposit line item displayed on the work queue;

(e) causing a match verification between the selected remittance advice line item and the selected deposit line item;

(f) determining if the match correctly corresponds to the deposit and, in the affirmative, deleting matches from the work queue and comparing non-matches to a predetermined threshold;

(g) creating a plan level item for matches found in step (f);

(h) reiterating steps (c) through (g) for items not found to match in step (f).

7. The method of claim 6, wherein the manual reconciliation process is initiated after a failed automatic attempt to match remittance advice batches and/or sub-batches to deposit batches and/or sub-batches.

8. The method of claim 1, wherein the manual reconciliation process is one which attempts to match remittance advice batches and/or sub-batches with prescription claims comprising the steps of:

(a) displaying a list of unresolved remittance advice batches or sub-batches remaining after completion of an automatic attempt to match remittance advice batches and/or sub-batches to individual prescription claims;

(b) selecting an unresolved remittance advice batch or sub-batch from the list;

(c) determining if a selected remittance advice line item(s) from the selected remittance advice batch or sub-batch is available for matching;

(d) building a work screen based on the selected remittance advice batch or sub-batch;

(e) selecting an unmatched remittance advice line item and an unmatched prescription claim item from the work screen;

(f) causing a match verification between the selected remittance advice line item and the unmatched prescription claim item;

(g) determining if the match correctly corresponds to the prescription claim item and, in the affirmative, deleting the matches from the work queue.

9. The method of claim 8, wherein the failure of step (g) to determine a correct match, results in additional user-interactive graphic display screens provided for a system user including claim history screens, side-by-side comparison screens showing specified remittance advice line items with prescription claims, screens to allow a user to perform a deposit transfer adjustment, and/or screens allowing user to manually enter remittance advice data.

10. The method of claim 1, wherein the step of automatically reconciling third party payor receivables includes the step of reconciling deposit batches or sub-batches with remittance advice batches or sub-batches wherein the remittance advice is identified with deposit identification.

11. The method of claim 10, wherein reconciliation determines a remittance advice sub-batch status of matched or unmatched.

12. The method of claim 11, wherein the remittance advice sub-batch status of unmatched results from the difference of remittance advice sub-batch monetary amount and third party deposit amount transgressing a predetermined monetary threshold.

13. The method of claim 1, wherein the step of automatically reconciling third party payor receivables includes the step of reconciling deposits with remittance advice sub-batches wherein the remittance advice sub-batch is identified by one of store identification and group identification.

14. The method of claim 13, wherein reconciliation determines a remittance advice sub-batch status of one of matched, unmatched, and ambiguous.

15. The method of claim 1, wherein the step of automatically reconciling third party payor receivables includes the step of reconciling unmatched remittance advice batches and/or sub-batches with unmatched deposits comprising the steps of:

(a) determining which processor identifiers require matching;

(b) selecting a processor identifier;

(c) selecting unmatched remittance advice batches and/or sub-batches associated with the selected processor identifier;

(d) selecting unmatched deposits associated with the selected processor identifier;

(e) compare sum money totals associated with the unmatched remittance advice batches and/or sub-batches with the sum money totals associated with the unmatched deposits;

(f) when money amounts match, changing the state of the remittance advice batches and/or sub-batches and deposit batches and/or sub-batches to a matched state;

(g) repeating steps (a) through (f) until remaining processor identifiers are examined.

16. The method of claim 1, wherein the step of automatically reconciling third party payor receivables includes the step of reconciling remittance advice line items from remittance advice batches previously matched to a deposit to individual prescription claims comprising the steps of:

(a) selecting remittance advice batches previously matched to a deposit;

(b) selecting prescription claims;

(c) selecting non-workers compensation claims;

(d) comparing the selected remittance advice line items to the selected prescription claims based on pass 1 parameters to ascertain which remittance advice line items are either matched or unmatched;

(e) performing step (d) using the remaining remittance advice line items and the selected prescription claims based on pass 2 parameters;

(f) performing step (e) using the remaining remittance advice line items and the selected prescription claims based on pass 3 parameters;

(g) performing step (f) using the remaining remittance advice line items and the selected prescription claims based on pass 4 parameters;

(h) performing step (g) using the remaining remittance advice line items and the selected prescription claims based on pass 5 parameters;

(i) determining if the selected remittance advice batches have a truncated prescription number.

17. The method of claim 16, wherein a match determined in steps (d) or (e) results in updating the remittance advice line item to a state of matched and the prescription claim status is updated to reflect a match to the remittance advice line item.

18. The method of claim 16, wherein a match for all variables, except a date of service variable within a predetermined range, determined in steps (f) or (g) results in updating the remittance advice line item(s) to a state of matched and the prescription claim status is updated to reflect a match to the remittance advice line item.

19. The method of claim 16, wherein a match for all variables, except a date of service variable within a predetermined range, determined in step (h), results in updating the prescription claim state to reflect a need for a manual remittance advice to claim matching process.

20. The method of claim 16, wherein remittance advice batches determined to have truncated Rx numbers in step (i) are compared to claims based on pass 6 parameters to ascertain which remittance advice line item(s) are either matched or are unmatched.

21. The method of claim 20, wherein unmatched remittance advice line item(s) reflect a need for a manual remittance advice to claim matching process.

22. The method of claim 20, wherein matched remittance advice line item(s) result in updating the remittance advice line item(s) to a state of matched and the prescription claim status is updated to reflect a match to the remittance advice line item(s).

23. The method of claim 16, wherein the step of automatically reconciling third party payor receivables includes the step of reconciling remittance advice line items from remittance advice batches having claims determined to be of the type workers compensation, comprising the steps of:

(a) comparing the selected remittance advice line items to the selected prescription claims based on pass 1 parameters to ascertain which remittance advice line items are either matched or unmatched;

(b) performing step (a) using the remaining remittance advice line items and the selected prescription claims based on pass 2 parameters;

(c) performing step (b) using the remaining remittance advice line items and the selected prescription claims based on pass 3 parameters;

(d) performing step (c) using the remaining remittance advice line items and the selected prescription claims based on pass 4 parameters;

(e) performing step (d) using the remaining remittance advice line items and the selected prescription claims based on pass 5 parameters;

(f) performing step (e) using the remaining remittance advice line items and the selected prescription claims based on pass 6 parameters.

24. The method of claim 23, wherein a match for all variables, except a date of service variable within a predetermined range, determined in step (a) or (e), results in updating the remittance advice line item(s) to a state of matched and the prescription claim status is updated to reflect a match to the remittance advice line item(s).

25. The method of claim 23, wherein a match for all variables determined in step (b) results in updating the remittance advice line item(s) to a state of matched and the prescription claim status is updated to reflect a match to the remittance advice line item(s).

26. The method of claim 23, wherein a match for all variables determined in step (c) or (d), and an exact match based on an invoice identification number, and a match based on a predetermined money amount range, result in updating the remittance advice line item(s) to a state of matched and the prescription claim status is updated to reflect a match to the remittance advice line item(s).

27. The method of claim 23, wherein a match for all variables, except a date of service variable within a predetermined range, determined in step (f), results in updating the prescription claim state to reflect a need for a manual remittance advice to claim matching process.

28. The method of claim 1, wherein the step of automatically reconciling third party deposit data results in a positive identification of one of the following claim statuses:

claim is manual, claim requires special handling, an identification of a failure to match deposit data to remittance advice, and an identification of a failure to match claims to remittance advice;

further comprising the step of evaluating at least one of a plurality of claim status parameters.

29. The method of claim 28, wherein the plurality of claim status parameters include missing deposit, non-sufficient funds, stop payment, suspended claim, claim without matching remittance advice, short paid claim, plan audit, claim audit, manual claim, special handling claim, claim determined to require rebilling, rejected claim, contested chargeback claim, claim requiring retroactive billing to a third party, claim requiring refund/payback to a third party, and/or a claim having a credit balance.

30. The method of claim 29, wherein an affirmative claim status parameter results in initiating at least one of a plurality of processes.

31. The method of claim 30, wherein the processes include collections, billing, billing exceptions, and payment exceptions.

32. The method of claim 1, wherein the step of automatically reconciling third party deposit data results in an identification of a claim to have a status of either resolution requires adjustment, resolution requires a claim search, or resolution requires a claim history search.

33. The method of claim 32, wherein a claim identified as requiring adjustment facilitates a plurality of user interactive graphic display screens to allow a system user to adjust prescription claim information.

34. The method of claim 32, wherein a claim identified as requiring a claim search facilitates a plurality of user interactive graphic display screens to allow a system user to search a plurality of criteria in the PARS database.

35. The method of claim 32, wherein a claim identified as requiring a claim history search facilitates a plurality of user interactive graphic display screens to allow a system user to view claim history and its associated criteria.

36. An apparatus for reconciling third party payor receivables with a set of prescription transactions, the apparatus comprising:

a pharmacy workstation constructed to render a plurality of user-interactive graphic display screens;

a pharmacy accounts receivable system (PARS) database constructed to receive prescription claim data, third party deposit data, third party payor data, and remittance advice associated with the set of prescription transactions, the remittance advice comprising a plurality of remittance advice line items, each remittance advice line item associated with one of the prescription transactions of the set of prescription transactions;

a PARS controller comprising a processor and a memory operatively coupled to the processor,

the PARS controller operatively coupled to the pharmacy workstation and the PARS database, the PARS controller being programmed to configure the prescription claim data, the third party deposit data, the third party payor data, and the remittance advice into the PARS database to form PARS data;

the PARS controller being programmed to generate a plurality of user-interactive graphic display screens based on the PARS data;

the PARS controller being programmed to automatically reconcile third party deposit data, wherein the PARS controller is further programmed to automatically facilitate at least one of a process of automatic reconciliation and manual reconciliation.

37. The apparatus of claim 36, wherein the PARS controller is programmed to automatically identify prescription transactions representing a need for manual reconciliation by a PARS user.

38. The apparatus of claim 36, wherein the PARS controller is programmed to enable manual matching of remittance advice to deposits.

39. The apparatus of claim 38, wherein the PARS controller is programmed to facilitate manual matching by using the plurality of user-interactive graphic displays.

40. The apparatus of claim 36, wherein the PARS controller is programmed to enable manual matching of remittance advice to prescription claims.

41. The apparatus of claim 40, wherein the PARS controller is programmed to facilitate manual matching by using the plurality of user-interactive graphic displays.

42. The apparatus of claim 36, wherein the PARS controller is programmed to automatically reconcile third party payor receivables by matching remittance advice with deposits.

43. The apparatus of claim 42, wherein the PARS controller is further programmed to automatically reconcile third party payor receivables by matching remittance advice with deposits, wherein the remittance advice is identified with deposit identification.

44. The apparatus of claim 42, wherein the PARS controller is further programmed to automatically reconcile third party payor receivables by matching remittance advice with deposits, wherein the remittance advice is identified by one of store identification and group identification.

45. The apparatus of claim 42, wherein the PARS controller is further programmed to automatically reconcile third party payor receivables by matching remittance advice with deposits;

and

wherein the remittance advice is associated with a processor identifier and sum money totals associated with the remittance advice are compared to sum money totals of the deposits to form remittance advice states of either matched or unmatched.

46. The apparatus of claim 45, wherein the PARS controller is further programmed to iterate a plurality of processor identifiers.

47. The apparatus of claim 36, wherein the PARS controller is programmed to automatically reconcile third party payor receivables by matching remittance advice to prescription claims, wherein the remittance advice has already been matched to a deposit.

48. The apparatus of claim 47, wherein the PARS controller is further programmed to automatically compare a plurality of parameters for a match condition.

49. The apparatus of claim 48, wherein the PARS controller is further programmed to evaluate a plurality of parameter thresholds.

50. The apparatus of claim 36, wherein the PARS controller is programmed to automatically reconcile third party payor receivables by matching remittance advice to prescription claims, wherein the remittance advice is of type workers compensation.

51. The apparatus of claim 50, wherein the PARS controller is further programmed to automatically compare a plurality of parameters for a match condition.

52. The apparatus of claim 51, wherein the PARS controller is further programmed to evaluate a plurality of parameter thresholds.

53. The apparatus of claim 36, wherein the PARS controller is further programmed to identify one of the claim statuses in the group comprising:

manual claim, claim requiring special handling, failure to match deposit data to remittance advice, and failure to match claims to remittance advice; and

the PARS controller further programmed to evaluate at least one of a plurality of claim status parameters.

54. The apparatus of claim 53, wherein the PARS controller is further programmed to initiate at least one of a plurality of processes when at least one of the plurality of claim status parameters results in an affirmative state.

55. The apparatus of claim 53, wherein the PARS controller is further programmed to include a claim status parameter of the group of claim status parameters comprising:

missing deposit, non-sufficient funds, stop payment, suspended claim, claim without matching remittance advice, short paid claim, plan audit, claim audit, manual claim, special handling claim, claim determined to require rebilling, rejected claim, contested chargeback claim, claim requiring retroactive billing to a third party, claim requiring refund/payback to a third party, and a claim having a credit balance.

56. The apparatus of claim 54, wherein the PARS controller is further programmed to include the plurality of processes including collections, billing, billing exceptions, and payment exceptions.

57. The apparatus of claim 36, wherein the PARS controller is programmed to ascertain a claim status of requiring adjustment, requiring a claim search, or requiring a claim history search in order to reconcile;

and

wherein the PARS controller is further programmed to facilitate a plurality of user interactive graphic display screens to allow a system user to either adjust prescription claim information, search a plurality of criteria in the PARS database, or to search and view claim history and its associated criteria.