Multiple eligibility medical claims recovery system

• US 20040073456A1
• Filed: 06/06/2003
• Published: 04/15/2004
• Est. Priority Date: 06/07/2002
• Status: Abandoned Application

• Current Assignee: Fraudfind, LLC
• Original Assignee: Fraudfind, LLC
• Inventors: DiMaggio, John, Gottlieb, Joshua L., McManus, W. Michael, Kohl, Simeon
• Application Number:
  US10/456,938
• Publication Number:
  US 20040073456A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A multiple eligibility medical claims recovery architecture. A system is provided to perform post-processing of existing claims that were incorrectly filed in accordance existing claims reimbursement rules and regulations. The system is operable to further provide filtering, either locally or remotely, of claims submitted by a health care provider to a payor in a multiple-eligibility regime. Still further, the system is configurable to provide automatic filing of the claims to multiple payors on behalf of the health care provider. A system is provided to interact with other (PBM) systems and technology to provide real-time processing of claims submitted to determine if claims are correctly filed, pass those that are and reject those that are not and provide a means by which such rejected claims can be completed and redirected to the appropriate payer for approval and payment.

Claims

1. A managing system comprising:

a service provider system for submitting a multiple-eligible reimbursement claim for at least one of goods and services;

a primary payor system for reimbursing claims for a first category of at least one of goods and services;

at least one secondary payor for reimbursing claims for a second category of at least one of goods and services;

wherein the primary payor system comprises a primary implementation for receiving the multiple-eligible reimbursement claim from the service provider system, issuing suitable reimbursement to the service provider system and filing a cross-over claim with at least one secondary provider system; and

wherein the secondary payor system comprises a secondary implementation for receiving the cross-over claim from the primary payor system and issuing suitable reimbursement to the service provider system.

2. The managing system of claim 1 wherein the primary payor system comprises a claims database including a primary payor eligibility information database.

3. The managing system of claim 2 wherein the secondary payor system further comprises:

an implementation for accessing the primary payor eligibility information database to obtain primary payor eligibility information, and combining with secondary payor eligibility information, to create a dual-eligibility file for a particular dual-eligible reimbursement claim; and

a benefits manager system for receiving the dual-eligibility file, for maintaining a paid claim information database, and for returning a paid claim file to the secondary payor system.

4. The managing system of claim 3 further comprising a recovery system for incorrectly-filed and paid claims including:

a solutions system for receiving the dual-eligibility file and the paid claim file from the secondary payor system, creating a file of suspected incorrectly-paid dual eligible claims, and returning to the secondary payor system the file of suspected incorrectly-paid dual eligible claims;

an implementation of the secondary payor system for issuing a notice of recovery to the service provider system in order to recover an incorrectly-paid claim;

an implementation of the service provider for resubmitting the claim with the primary payor system upon recovery by the secondary payor system.

5. The managing system of claim 4 wherein the solutions system includes a claim processing system for determining whether the multiple-eligible reimbursement claim has sufficient information and comprises:

an implementation for notifying the service provider system if additional information is required; and

an implementation for performing internal corrections, formatting the data and filing the claim electronically with the primary payor system if no additional information is required.

6. The managing system of claim 5 wherein the primary payor system is Medicare and the secondary payor system is Medicaid and wherein the solutions system is configured to determine whether the multiple-eligible reimbursement claim includes at least one of:

a service provider Medicare number;

a patient social security number, a patient Medicare number;

a doctor name;

a doctor UPIN (Unique Physician Identification Number);

an HCPCS (HCFA Common Procedure Coding System); and

an ICD-9 diagnosis code.

7. The managing system of claim 4 wherein the solutions system further comprises a claim data collector implementation, residing on a local computer system, comprising:

a software program for accessing a database of historical claim information from the secondary payor system, wherein the database includes data selected from at least one of;

information sent by the service provider to the secondary payor for an original claim, extra information provided by the solutions system from the secondary payor'"'"'s files, information from the files created by the solutions system, a service recipient'"'"'s social security number, a primary payor ID number, a service provider'"'"'s name, and an identifying code; and

an implementation for enabling the service provider system to review each data item for verification and correction.

8. The managing system of claim 4 wherein the recovery system further comprises an implementation for providing real-time capture and resolution of an incorrectly-filed multiple-eligible reimbursement claim comprising:

an implementation of the benefits manager for comparing a claim against the multiple-eligible coverage data to determine if the claim should have been first filed with the primary payor system;

an implementation for generating and transmitting a redirection notice back to the service provider system, directing the service provider to route an incorrectly-filed claim to the solutions system;

an implementation of the solutions system for sending to the service provider an eligibility-and-capture notice indicating that the solutions system has checked the claim information against its product set data and that additional information is required;

an implementation of the solutions system, upon receipt of additional information from the service provider, for correctly filing the claim with the primary payor system.

9. The managing system of claim 4 further comprising a remote intercept system for determining if the multiple-eligible reimbursement claim is filed correctly with the secondary payor system, the remote intercept system comprising:

an implementation for remotely intercepting a claim filed by a service provider system;

an implementation for comparing the claim with the dual eligibility coverage database and the dual eligibility product set to determine if the claim was filed correctly with the secondary payor system;

an implementation for issuing a redirection notice back to the service provider system if the claim is determined to have been filed incorrectly.

10. The managing system of claim 9 wherein the implementation for comparing determines if the claim should be forwarded through to the secondary payor system, or if the claim is an incorrectly filed dual-eligible claim that should be redirected, and wherein if the claim is a multiple-eligible claim, yet not filed incorrectly, again, the claim is forwarded to the appropriate payor system, and wherein if the claim is both a dual-eligible, and an incorrectly filed claim, the claim data is stored for subsequent processing.

11. The managing system of claim 4 wherein the service provider system further comprises:

a local intercept system for determining if the multiple-eligible reimbursement claim is filed correctly with the secondary payor system, the local intercept system comprising;

an implementation for determining whether a claim is incorrectly filed with the secondary payor system and forwarding to the primary payor system;

an implementation for extracting additional information from the service provider system to complete processing for filing with the primary payor system.

12. The managing system of claim 11 wherein the local intercept system further comprises an implementation for remotely receiving updated database information from the solutions system.

13. The managing system of claim 1 wherein the service provider system is for a health care provider selected from a group including a pharmacy, a physician, and a similar entity and wherein at least one of first and second categories of goods and services is selected from a group comprising at least one of medical supplies, drugs, and medical services to a patient, and wherein the primary and secondary payor systems represent medical insurance entities.

14. The managing system of claim 13 wherein the primary payor system represents Medicare and the secondary payor system represents Medicaid.

15. A method comprising:

submitting a multiple-eligible reimbursement claim to a primary payor for at least one of goods and services;

issuing reimbursement from the primary payor for a first category of at least one of goods and services;

filing a cross-over claim from the primary payor to a secondary payor for a second category of at least one of goods and services; and

issuing reimbursement from the secondary payor for the second category of at least one of goods and services.

16. The method of claim 15 further comprising a method of recovery for incorrectly filed claims comprising:

combining primary payor eligibility information with secondary payor eligibility information, to create a dual-eligibility file of dual-eligible reimbursement claims;

comparing the dual-eligibility file with a paid claim file to create a file of incorrectly-paid dual eligible claims;

recovering a reimbursement for an incorrectly-paid dual-eligible claim;

resubmitting the incorrectly-paid dual eligible claim to the primary payor upon recovery of the incorrectly-paid dual eligible claim.

17. The method of claim 16 further comprising a method determining whether the multiple-eligible reimbursement claim has sufficient information, comprising the additional steps of:

notifying if additional information is required; and

performing internal corrections, formatting the data and filing the claim electronically with the primary payor system if no additional information is required.

18. The method of claim 17 wherein the primary payor system is Medicare and the secondary payor system is Medicaid and wherein, in the step of notifying, the additional information includes at least one of:

a service provider Medicare number;

a patient social security number, a patient Medicare number;

a doctor name;

a doctor UPIN (Unique Physician Identification Number);

an HCPC (HCFA Common Procedure Coding System); and

an ICD-9 diagnosis code.

19. The method of claim 16 wherein the method of recovery further comprises:

locally accessing a database of historical claim information from the secondary payor system, wherein the database includes data selected from at least one of;

information sent by the service provider to the secondary payor for an original claim, extra information provided by the solutions system from the secondary payor'"'"'s files, information from the files created by the solutions system, a service recipient'"'"'s social security number, a primary payor ID number, a service provider'"'"'s name, and an identifying code; and

reviewing each data item for verification and correction.

20. The method of claim 16 wherein the method of recovery further comprises:

a method for providing real-time capture and resolution of an incorrectly-filed multiple-eligible reimbursement claim comprising the steps of;

comparing a claim against the multiple-eligible coverage data to determine if the claim should have been first filed with the primary payor system;

generating and transmitting a redirection notice to route an incorrectly-filed claim to the solutions system;

sending an eligibility-and-capture notice indicating that the claim information has been checked against product set data and that additional information is required;

correctly filing the claim with the primary payor system upon receipt of additional information.

21. The method of claim 16 further comprising a method of determining if the multiple-eligible reimbursement claim is filed correctly with the secondary payor system, the method comprising:

remotely intercepting a claim;

comparing the claim with the dual eligibility coverage database and the dual eligibility product set to determine if the claim was filed correctly with the secondary payor system;

issuing a redirection notice if the claim is determined to have been filed incorrectly.

22. The method of claim 21 wherein the step of comparing determines whether the claim should be forwarded through to the secondary payor system, or if the claim is an incorrectly filed dual-eligible claim that should be redirected, and wherein if the claim is a multiple-eligible claim, yet not filed incorrectly, again, a step is performed of forwarding the claim to the appropriate payor system, and wherein if the claim is both a dual-eligible, and an incorrectly filed claim, a step is performed of storing the claim data for subsequent processing.

23. The method of claim 16 further comprising the steps of:

locally intercepting the multiple-eligible reimbursement claim;

determining if the claim is filed correctly with the secondary payor system;

forwarding an incorrectly filed claim to the primary payor system;

extracting additional information to complete processing for filing with the primary payor system.

24. The method of claim 15 wherein the step of submitting is performed by a health care provider selected from a group including a pharmacy, a physician, and a similar entity and wherein at least one of first and second categories of goods and services is selected from a group comprising at least one of medical supplies, drugs, and medical services to a patient, and wherein the primary and secondary payors represent medical insurance entities.

25. The method of claim 24 wherein the primary payor represents Medicare and the secondary payor represents Medicaid.