System and method for reconciling an insurance payment with an insurance claim

• US 20050043972A1
• Filed: 04/30/2004
• Published: 02/24/2005
• Est. Priority Date: 05/01/2003
• Status: Abandoned Application

• Current Assignee: PEP Systems, Inc.
• Original Assignee: PEP Systems, Inc.
• Inventors: Webb, Jon A., Kossol, Joyce L.
• Application Number:
  US10/837,111
• Publication Number:
  US 20050043972A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/04 Payment circuits
• CPC Class Codes: G06Q 20/389 Keeping log of transactions for guaranteeing non-repudiation of a transaction
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

Disclosed herein is a method for reconciling an insurance payment to an entity, such as a pharmacy, with an insurance claim made by the entity. Some embodiments of the method comprise providing a claim value belonging to a set of claim values, providing a claim identification value associated with the claim value and belonging to a set of claim identification values, providing a payment value belonging to a set of payment values, providing a payment identification value associated with the payment value and belonging to a set of payment identification values and, where the payment identification value and the claim identification value correspond to each other, matching the payment value with the claim value. Additional systems and methods are also disclosed herein.

Claims

1. A method for reconciling an insurance payment to an entity, such as a pharmacy, with an insurance claim made by the entity, comprising:

providing a claim value belonging to a set of claim values;

providing a claim identification value associated with the claim value and belonging to a set of claim identification values;

providing a payment value belonging to a set of payment values;

providing a payment identification value associated with the payment value and belonging to a set of payment identification values; and

where the payment identification value and the claim identification value correspond to each other, matching the payment value with the claim value.

2. The method of claim 1, comprising:

where the payment value and the claim value are matched, comparing the payment value and the claim value to identify at least one of underpayment, overpayment, and accurate payment.

3. The method of claim 1, comprising:

indicating a missing payment, where the claim value is unmatched with each member of the set of payment values; and

indicating a misdirected payment, where the payment value is unmatched with each member of the set of claim values.

4. The method of claim 1, comprising forming a filter expression from a scan of a remittance document.

5. The method of claim 1, comprising scanning a remittance document that articulates a plurality of itemized payments and a plurality of itemized identifications, and that indicates an association between each of the plurality of itemized payment with at least one of the plurality of itemized identifications.

6. The method of claim 5, comprising defining the association between the payment value and the payment identification value based at least in part on the indicated associations.

7. The method of claim 6, comprising defining an association between another member of the set of payment values and another member of the set of payment identification values based at least in part on an association between another itemized payment and another itemized identification.

8. The method of claim 1, comprising verifying at least one of a match, an anomalous payment, an underpayment, an overpayment and an accurate payment.

9. The method of claim 5, comprising providing an emulation of the remittance document having an emulation layout substantially similar to a document layout of the remittance document.

10. The method of claim 1, wherein the claim identification value and the payment identification value each comprises a data item representative of at least one of a pharmacy customer, a prescription number, a date, a price code, a sale number, a social security number and a sale quantity.

11. The method of claim 10, comprising corresponding the payment value and the claim value with each other when the data items of associated claim identification values and payment identification values are the same.

12. The method of claim 10, comprising corresponding the payment value and the claim value with each other when the data items of associated claim identification values and payment identification values are related.

13. The method of claim 1, comprising importing at least one of the claim value and the claim identification value from an external application while maintaining the association between the claim value and the claim identification value.

14. The method of claim 13, comprising exporting the claim value and the payment value to the external application, while maintaining a relationship between the claim value and the payment value.

15. The method of claim 13, comprising posting the payment value to the external application, while maintaining a relationship between the claim value and the payment value.

16. The method of claim 1, comprising receiving at least one of the claim value and the claim identification value from a database, while maintaining the association between the claim value and the second identification value.

17. The method of claim 16, comprising sending the claim value and the payment value to the database, while maintaining a relationship between the claim value and the payment value.

18. The method of claim 16, comprising posting the payment value, while maintaining a relationship between the claim value and the payment value.

19. A method for reconciling an insurance payment to an entity, such as a pharmacy, with an insurance claim made by the entity, comprising:

providing a claim value belonging to a set of claim values;

providing a claim identification value associated with the claim value and belonging to a set of claim identification values;

scanning a remittance document that articulates a plurality of itemized payments and a plurality of itemized identifications and associates an itemized payment with an itemized identification;

defining an association between a payment value and a payment identification value based at least in part on the association between the itemized payment and the itemized identification;

providing the payment value and the payment identification value;

where the payment identification value and the claim identification value correspond to each other, matching the payment value with the claim value;

where the payment value is unmatched with each member of the set of claim values, indicating a misdirected payment; and

where the claim value is unmatched with each member of the set of payment values, indicating a missing payment.

20. The method of claim 19, comprising forming a filter expression from the scan.

21. The method of claim 19, comprising defining an association between another payment value and another payment identification value based at least in part on an association between another itemized payment and another itemized identification.

22. The method of claim 19, comprising verifying at least one of an underpayment, an overpayment and an accurate payment.

23. The method of claim 19, comprising providing an emulation of the remittance document having an emulation layout substantially similar to a document layout of the remittance document.

24. The method of claim 19, wherein at least one of the claim identification value and the payment identification value comprise a data item representative of at least one of a pharmacy customer, a prescription number, a date, a price code, a sale number, a social security number and a sale quantity.

25. The method of claim 24, comprising corresponding the payment value and the claim value with each other when the data items of associated claim identification values and payment identification values are the same.

26. The method of claim 24, comprising corresponding the payment value and the claim value with each other when the data items of associated claim identification values and payment identification values are related.

27. The method of claim 19, comprising importing at least one of the claim value and the claim identification value from an external application while maintaining the association between the claim value and the claim identification value.

28. The method of claim 27, comprising exporting the payment value to the external application, while maintaining a relationship between the claim value and the payment value.

29. The method of claim 27, comprising posting the payment value to the external application, while maintaining a relationship between the claim value and the payment value.

30. The method of claim 19, comprising receiving at least one of the claim value and the claim identification value from a database, while maintaining the association between the claim value and the claim identification value.

31. The method of claim 19, comprising sending the payment value to the database, while maintaining a relationship between the claim value and the payment value.

32. The method of claim 19, comprising posting the payment value, while maintaining a relationship between the claim value and the payment value.

33. A system for reconciling an insurance payment to an entity, such as a pharmacy, with an insurance claim made by the entity, comprising a computer-readable medium having stored thereon computer-executable instructions for performing the following:

providing a claim value belonging to a set of claim values;

providing a claim identification value associated with the claim value and belonging to a set of claim identification values;

providing a payment value belonging to a set of payment values;

providing a payment identification value associated with the payment value and belonging to a set of payment identification values; and

where the payment identification value and the claim identification value correspond to each other, matching the payment value with the claim value.

34. The system of claim 33, wherein the computer-readable medium has stored thereon computer-executable instructions for performing the following:

where the payment value is unmatched with each member of the set of claim values, indicating an anomalous payment.

35. The system of claim 33, wherein the computer-readable medium has stored thereon computer-executable instructions for performing the following:

where the claim value is unmatched with each member of the set of payment values, indicating a missing payment.

36. The system of claim 33, wherein the computer-readable medium has stored thereon computer-executable instructions for forming a filter expression from a scan of an itemized remittance document.

37. The system of claim 33, wherein the computer-readable medium has stored thereon computer-executable instructions for scanning a remittance document that articulates a plurality of itemized payments and a plurality of itemized identifications and associates an itemized payment with an itemized identification.

38. The system of claim 37, comprising a scanner.

39. The system of claim 37, wherein the computer-readable medium has stored thereon computer-executable instructions for defining the association between the payment value and the payment identification value based at least in part on the association between the itemized payment and the itemized identification.

40. The system of claim 37, wherein the computer-readable medium has stored thereon computer-executable instructions for defining an association between another member of the set of payment values and another member of the set of payment identification values based at least in part on an association between another itemized payment and another itemized identification.

41. The system of claim 35, wherein the computer-readable medium has stored thereon computer-executable instructions for verifying at least one of a match, an anomalous payment, an underpayment, an overpayment and an accurate payment by, where the payment value and the claim value are matched, comparing the payment value and the claim value to identify at least one of underpayment, overpayment, and accurate payment.

42. The system of claim 41, wherein the computer-readable medium has stored thereon computer-executable instructions for providing a printed emulation of the remittance document having an emulation layout substantially similar to a document layout of the remittance document.

43. The system of claim 42 comprising a printer.

44. The system of claim 33, wherein the claim identification value and the payment identification value each comprises a data item representative of at least one of a pharmacy customer, a prescription number, a date, a price code, a sale number, a social security number and a sale quantity.

45. The system of claim 44, wherein the computer-readable medium has stored thereon computer-executable instructions for corresponding the payment value and the claim value with each other when the data items of associated claim identification values and payment identification values are the same.

46. The system of claim 44, wherein the computer-readable medium has stored thereon computer-executable instructions for corresponding the payment value and the claim value with each other when the data items of associated claim identification values and payment identification values are related.

47. The system of claim 33, wherein the computer-readable medium has stored thereon computer-executable instructions for importing at least one of the claim value and the claim identification value from an external application while maintaining the association between the claim value and the claim identification value.

48. The system of claim 47, wherein the computer-readable medium has stored thereon computer-executable instructions for exporting the payment value to the external application, while maintaining a relationship between the claim value and the payment value.

49. The system of claim 47, wherein the computer-readable medium has stored thereon computer-executable instructions for posting the payment value to the external application, while maintaining a relationship between the claim value and the payment value.

50. The system of claim 47, comprising the external application.

51. The system of claim 33, wherein the computer-readable medium has stored thereon computer-executable instructions for receiving at least one of the claim value and the claim identification value from a database, while maintaining a relationship between the claim value and the payment value.

52. The system of claim 51, wherein the computer-readable medium has stored thereon computer-executable instructions for sending the payment value to the database, while maintaining a relationship between the claim value and the payment value.

53. The system of claim 51, wherein the computer-readable medium has stored thereon computer-executable instructions for posting the payment value to the database, while maintaining a relationship between the claim value and the payment value.

54. The system of claim 51, comprising the database.

55. The system of claim 33, comprising a processor for executing the instructions.

56. A method for reconciling insurance payments with insurance claims, comprising:

receiving a plurality of unpaid claim records;

creating a plurality of payment records from a scanned remittance document; and

matching at least one of the plurality of unpaid claim records with a corresponding one of the plurality of payment records to form a reconciled claim record.

57. The method of claim 56, comprising scanning the remittance document.

58. The method of claim 56, comprising comparing the at least one unpaid claim record against a corresponding one of the payment records to identify one of an underpayment, an overpayment, and an accurate payment.

59. The method of claim 58, comprising indicating the one of the underpayment, the overpayment and the accurate payment.

60. The method of claim 56, comprising verifying the accuracy of information making-up the reconciled claim record.

61. The method of claim 56, wherein receiving comprises receiving from an external application

62. The method of claim 61, comprising exporting the reconciled claim record to an external application, and wherein receiving comprises importing the unpaid claim record from the external application.

63. The method of claim 61, wherein receiving comprises receiving the plurality of unpaid claim records from a database, and indicating comprises sending a plurality of reconciled claim records to the database.