System and method for managing liability insurer healthcare claims

• US 20050091080A1
• Filed: 10/27/2003
• Published: 04/28/2005
• Est. Priority Date: 10/27/2003
• Status: Abandoned Application

• Current Assignee: Great Lakes Holding, Inc.
• Original Assignee: Great Lakes Holding, Inc.
• Inventors: Biats, Carl G. Jr.
• Application Number:
  US10/694,120
• Publication Number:
  US 20050091080A1
• 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
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A system and method for managing liability insurer'"'"'s healthcare claims, allows liability insurers, such as property and casualty insurers, who have no direct policy relationship with patients for whom they become financially responsible, to take advantage of healthcare provider “rate regulations,” and “healthcare management,” including incentives, heretofore only available to healthcare insurers from healthcare providers within an “active network.” A system administrator manages clamant healthcare claims from member passive network healthcare providers for member liability insurers that become financially responsible for these claims as a result of the actions or inactions of their liability policyholders. The liability insurer members within the insurer network are in contractual relationship with the system administrator who is in contractual relationship with member healthcare providers of the passive healthcare provider network such that when a provider of healthcare product or service submits a claim, for which a system liability insurer member is financially responsible, the system administrator validates the claim as falling in the system; applies the provider network rules; and applies provider coverage rules to determine the level of coverage by the member liability insurer for the claim. Based on this determination, that portion of the claim covered by the member liability policy the Claimant is paid by the system administrator. In another aspect, an Allocation Fund is provided to pay claims where more than one system liability insurer may be liable for the claim.

Claims

1. A system for managing healthcare claims, for which liability insurers are financially responsible, comprising:

a) at least one system administrator in privity, directly or indirectly, with at least one healthcare provider member, and at least one liability insurer member;

b) at least one passive healthcare provider network including said at least one healthcare provider member having a set of network provider rules; and

,

c) at least one liability insurer network including said at least one liability insurer member having a set of policy rules wherein said at least one system administrator receives claims, applies said network provider rules, transmits said claim for application of said policy rules, and pays said claim in accordance therewith.

2. The system of claim 1 wherein said policy rules are applied by said at least one liability insurer member.

3. The system of claim 1 wherein said policy rules are applied by said at least one system administrator.

4. The system of claim 1 wherein said system is automated by means of application service provider having communication links among said at least one liability insurer member, said at least one system administrator, and;

said least one healthcare provider member.

5. The system of claim 4 wherein said communication links are selected from dial-up networking, Digital Subscriber Lines, Asymmetric Digital Subscriber Lines, Virtual Private Network, LAN, WAN, cable, IR, radio frequency, cell, Internet, Intranet, satellite, and combinations thereof.

6. The system of claim 1 wherein said claim is generated, at least in part, by said a least one healthcare provider member prior to providing healthcare.

7. The system of claim 1 wherein said claim is tested for compliance with the system criteria and then tested for systems eligibility prior to application of said network provider rules.

8. The system of claim 1 wherein said system includes a claim allocation fund.

9. The system of claim 8 wherein said at least on system administrator applies the allocation find rules as between potentially liable liability insurer members to establish initial allocated liability for payment of said claim.

10. The system of claim 1 wherein said system further comprises at least one pending claim database and at least one paid claim database in communication, one with the other.

11. The system of claim 1 wherein said claim is generated, at least in part by a Claimant.

12. The system of claim 1 wherein said claim is generated, at least in part by a member healthcare provider.

13. The system of claim 1, wherein the policy rules include protocol rules;

healing outcome rules; and

economic outcome rules.

14. The system of claim 13, wherein the policy rules further includes formulary rules;

utilization rules;

authorization rules; and

, deductible rules.

15. The system of claim 1, further comprising:

means for converting a first product code submitted with said claim to a more specific product code.

16. The system of claim 15, further comprising:

means for providing said more specific product code to the liability insurer.

17. A method for managing claims relating to healthcare provided by a member healthcare provider, for which a liability insurer, within a liability insurer network, is financially responsible, comprising the steps of:

a) receiving a claim for healthcare;

b) applying the network rules associated with a passive healthcare provider network in which said healthcare provider is a member, to the claim;

c) applying the policy rules associated with the member liability insurer network to the claim;

d) processing the appropriate payment of the claim.

18. The method of claim 17 comprising the further steps of establishing compliance and eligibility of the claim.

19. The method of claim 17 comprising determining the level of liability by each liability insurer member within a liability insurer network prior to processing said appropriate payment of the claim.

20. The method of claim 19 wherein a claim allocation fund is used to satisfy the level of financial liability of each liability insurer member for unresolved financial liability using allocation fund rules.

21. The method of claim 17 wherein a system administrator is used to facilitate the steps.

22. The method of claim 17 wherein said method is application service provider based.

23. A method for facilitating compliance with policy rules governing coverage by a liability insurer for healthcare provided to a Claimant by a member healthcare provider comprising the steps of:

b) receiving a liability generated claim for healthcare;

c) applying provider network rules to said claim;

d) determining the level of liability coverage for the claim; and

e) processing payment or authorization to provide healthcare for said claim based thereon.

24. The method of claim 23 wherein said method is application service provider based.

25. The method of claim 24 wherein a system administrator administers said application service provider based method.

26. The method of claim 23 wherein said application service provider based method utilizes communication links selected from dial-up networking, digital subscriber lines, Asymmetric Digital subscriber lines, virtual private network, LAN, WAN, cable, IR, radio frequency, cell, Internet, Intranet, and/or satellites.

27. The method of claim 23 wherein initial financial liability for said covered claim is resolved by use of allocation fund rules applied to a claim allocation fund.

28. The method of claim 23, wherein said claim includes Claimant information;

liability insurer information;

prescription information associated with the healthcare;

injury or wound information associated with the healthcare; and

combinations thereof.

29. The method of claim 28, wherein said information associated with the healthcare comprises a HCPCS product code corresponding to the healthcare.

30. The method of claim 29, wherein said HCPCS product code is mapped to a more specific product code.

31. The method of claim 30, wherein said more specific product code is provided to the liability insurer member.

32. The method of claim 23, wherein the rules governing coverage comprise:

protocol rules;

healing outcome rules; and

economic outcome rules.

33. The method of claim 32, wherein the rules governing coverage further comprise:

formulary rules;

utilization rules;

authorization rules;

co-payment rules; and

deductible rules.

34. The method of claim 23, wherein said authorization step further comprises:

initiating the release of the healthcare service from the provider to the Claimant.

35. The method of claim 23, further comprising:

automatically processing fulfillment of future claims determined by said authorization step.

36. The method of claim 23 wherein the method is applied to ancillary healthcare.

37. A system for facilitating compliance with policy rules governing coverage by a liability insurer for healthcare provided to a Claimant by a member healthcare provider, wherein the healthcare is administered under provider network rules in a passive healthcare provider network comprising:

a) means for receiving a liability claim for said healthcare;

b) means for applying said provider network rules associated with said passive healthcare provider network;

c) means for applying said policy rules governing coverage by a liability insurer of said claim;

d) means for approving the level of coverage by the liability insurer for said claim; and

,

e) means for processing payment for said claim.

38. The system of claim 37, wherein the rules governing coverage comprise:

protocol rules;

healing outcome rules; and

economic outcome rules.

39. The system of claim 38, wherein the rules governing coverage further comprise:

formulary rules;

utilization rules;

authorization rules; and

deductible rules.

40. The system of claim 37, further comprising:

means for converting a first product code submitted with said claim to a more specific product code.

41. The system of claim 40, further comprising:

means for providing said more specific product code to the liability insurer.

42. The system of claim 41, wherein the system is used for ancillary healthcare.

43. The system of claim 37 wherein said system is application service provider based.

44. The system of claim 43 wherein a system administrator administers said application service provider based method.

45. The system of claim 44 wherein said communication links are selected from dial-up networking, digital subscriber lines, asymmetric digital subscriber lines, virtual private network, LAN, WAN, cable, IR, radio frequency, cell, Internet, Intranet, satellite, and combinations thereof.

46. The system of claim 37 wherein said means for approval further comprises determining initial financial liability for said claim by use of allocation fund rules applied to a claim allocation fund.

47. The system of claim 37, wherein said claim includes Claimant information;

liability insurer information;

prescription information associated with the healthcare;

injury or wound information associated with the healthcare; and

combinations thereof.

48. The system of claim 47, wherein said information associated with the healthcare comprises a HCPCS product code corresponding to the Healthcare.

49. The system of claim 48, wherein said HCPCS product code is mapped to a more specific product code

50. The system of claim 49, wherein said more specific product code is provided to the liability insurer member.