System for monitoring payment for provision of services to an entity

• US 20040199406A1
• Filed: 02/06/2004
• Published: 10/07/2004
• Est. Priority Date: 03/07/2003
• Status: Abandoned Application

• Current Assignee: Siemens Medical Solutions Health Services Corporation (Siemens AG)
• Original Assignee: Siemens Medical Solutions Health Services Corporation (Siemens AG)
• Inventors: Owens, Raymond, Lozowski, Stephen, Cole, Douglas J., Digiacomo, Mike, Conti, Nicholas
• Application Number:
  US10/773,544
• Publication Number:
  US 20040199406A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A system for grouping records of charges associated with provision of services to an entity to support reimbursement monitoring includes an acquisition processor for acquiring data related to charges for services provided to the entity. A data processor is coupled to the acquisition processor and to a source of rules. The data processor groups the charges using the rules to provide a reimbursable amount value and creates a record containing data representing the grouped charges and the reimbursable amount value.

Claims

1. A system for grouping records of charges associated with provision of healthcare to a patient to support payment monitoring, comprising:

an acquisition processor for acquiring data related to charges for at least one encounter of a particular patient with a healthcare provider organization;

a source of rules for use in processing acquired charge data; and

a data processor using said acquired charge related data for creating a record grouping charges for provision of services associated with said at least one encounter and indicating an expected reimbursable amount value for said grouped charges, said charges being grouped using said rules to provide a reimbursable amount value expected from a payer organization.

2. A system according to claim 1, wherein said data processor groups charges expected to be reimbursed by said payer organization in a single payment remittance received by said healthcare provider organization, said charges being grouped based on at least one of, (a) a single individual charge comprises a group, (b) charges are grouped together in a claim to be submitted to a payer organization and (c) charges are grouped together as an item among a plurality of items in a claim to be submitted to a payer organization.

3. A system according to claim 1, further comprising a payment monitor for monitoring payments received for provision of services to patients by comparing said expected reimbursable amount in said created record with an amount identified in a received payment remittance.

4. A system according to claim 3, wherein in response to said comparison, said payment monitor generates an indication identifying at least one of, (a) said expected reimbursable amount in said created record matches an amount identified in a received payment remittance and (b) said expected reimbursable amount in said created record fails to match an amount identified in received payment remittances and action is required.

5. A system according to claim 1, wherein said data processor reallocates a charge in said created record to a different second created record in response to a received message identifying an event.

6. A system according to claim 5, wherein said identified event comprises at least one of, (a) a change in said rules used in processing acquired charge data and (b) an error in grouping said charges for provision of services in said created record.

7. A system according to claim 1, wherein said data processor creates said record by grouping charges in response to date of charge accrual and payer organization rules.

8. A system according to claim 7, wherein said payer organization rules comprise at least one of, (a) rules provided by a payer organization and (b) derived rules substituting for payer organization rules.

9. A system according to claim 1, wherein said data processor creates said record by grouping charges in response to payer organization rules comprising at least one of, (a) group together charges accruing within a first predetermined time period for multiple encounters of said particular patient with said healthcare provider organization, (b) group together charges accruing within a second predetermined time period for a single encounter of said particular patient with said healthcare provider organization, said single encounter having a duration comprising a plurality of said second predetermined time periods, (c) group together charges accruing in response to a single encounter of said particular patient with said healthcare provider organization, and (d) group together charges accruing in response to multiple encounters of said particular patient with said healthcare provider organization.

10. A system according to claim 9, wherein said first predetermined time period and said second predetermined period comprise at least one of, (i) a day, (ii) a week, (iii) a month, (iv) multiple months and (v) a payer organization defined period.

11. A system according to claim 1, wherein:

said particular patient comprises a plurality of related patients;

said acquisition processor acquires data related to charges for said at least one encounter of said plurality of related patients, and

said data processor uses said acquired charge related data for creating a record grouping charges for provision of services to said plurality of related patients.

12. A system for monitoring payment for provision of healthcare to a patient, comprising:

an acquisition processor for acquiring data related to charges for at least one encounter of a particular patient with a healthcare provider organization;

a data processor using said acquired charge related data for creating a record grouping charges for provision of services associated with said at least one encounter and indicating an expected reimbursable amount for said grouped charges, said charges being grouped in response to date of charge accrual and predetermined rules to provide a reimbursable amount value expected from a payer organization; and

a payment monitor for monitoring payments received for provision of services to patients by comparing said expected reimbursable amount in said created record with an amount identified in a received payment remittance.

13. A system according to claim 12, wherein said data processor groups charges expected to be reimbursed by said payer organization in a single payment remittance received by said healthcare provider organization, said charges being grouped based on at least one of, (a) a single individual charge comprises a group, (b) charges are grouped together in a claim to be submitted to a payer organization and (c) charges are grouped together as an item among a plurality of items in a claim to be submitted to a payer organization.

14. A system according to claim 12, wherein said data processor creates said record by grouping charges in response to payer organization rules comprising at least one of, (a) group together charges accruing within a first predetermined time period for multiple encounters of said particular patient with said healthcare provider organization, (b) group together charges accruing within a second predetermined time period for a single encounter of said particular patient with said healthcare provider organization, said single encounter having a duration comprising a plurality of said second predetermined time periods, (c) group together charges accruing in response to a single encounter of said particular patient with said healthcare provider organization, and (d) group together charges accruing in response to multiple encounters of said particular patient with said healthcare provider organization.

15. A system according to claim 12, wherein:

said acquisition processor acquires data related to charges for a plurality of encounters of a particular patient with a plurality of healthcare provider organizations, and

said data processor uses said acquired charge related data for creating a record grouping charges for provision of services associated with said plurality of encounters and indicates an expected reimbursable amount for said grouped charges by an individual healthcare provider organization of said plurality of healthcare provider organizations.

16. A system according to claim 12, wherein:

said acquisition processor acquires data related to charges for at least one patient encounter of a particular patient with a healthcare provider organization, and

said data processor uses said acquired charge related data for creating records grouping charges by responsible entity comprising at least one of, (a) an insurance company and (b) a guarantor.

17. A method for grouping records of charges associated with provision of healthcare to a patient to support payment monitoring, comprising the activities of:

acquiring data related to charges for at least one encounter of a particular patient with a healthcare provider organization;

applying rules for grouping said charges to provide a reimbursable amount value expected from a payer organization, using said acquired charge related data; and

creating a record grouping charges for provision of services associated with said at least one encounter and indicating said expected reimbursable amount value for said grouped charges.

18. A system according to claim 17, comprising a computer readable storage medium incorporating computer processor readable instruction for performing the activities of claim 17.

19. A system for grouping records of charges associated with provision of services to an entity to support reimbursement monitoring, comprising:

an acquisition processor for acquiring data related to charges for services provided to the entity;

a source of rules for use in processing the acquired charge data; and

a data processor, coupled to the acquisition processor and rules source, for grouping the charges using the rules to provide a reimbursable amount value and creating a record containing data representing the grouped charges and the reimbursable amount value.

20. A method for monitoring payment for provision of healthcare to a patient, comprising the activities of:

acquiring data related to charges for at least one encounter of a particular patient with a healthcare provider organization;

generating a record grouping charges for provision of services associated with said at least one encounter and indicating an expected reimbursable amount for said grouped charges, said charges being grouped in response to date of charge accrual and predetermined rules to provide a reimbursable amount value expected from a payer organization using said acquired charge related data; and

monitoring payments received for provision of services to patients by comparing said expected reimbursable amount in said created record with an amount identified in a received payment remittance.

21. A method for grouping records of charges associated with provision of services to an entity to support reimbursement monitoring, comprising the activities of:

acquiring data related to charges for services provided to the entity;

applying rules to the acquired charge data for grouping the charges to provide a reimbursable amount value; and

creating a record containing data representing the grouped charges and the expected reimbursable amount value.