Direct connectivity system for healthcare administrative transactions

• US 20050288972A1
• Filed: 06/27/2005
• Published: 12/29/2005
• Est. Priority Date: 06/28/2004
• Status: Active Grant

• Current Assignee: Accenture Global Services Limited (Accenture PLC)
• Original Assignee: Accenture Global Services GmbH (Accenture PLC)
• Inventors: Marvin, William F., Seib, Christopher D.
• Granted Patent: US 9,020,826 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/14 specially adapted for billing systems
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• 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 direct connectivity system provides automated healthcare administrative transaction submission, including claim submission, eligibility verification and claim status, from healthcare service providers directly to payers. The direct connectivity system bypasses transaction processing intermediaries such as clearinghouses by directly connecting providers to payers in a many to many manner. Existing single payer web portals are supplanted by a many to many network that has a common interface across multiple payers. The direct connectivity system may receive responses directly from payers and may prepare or process the responses for a practice management program so that the service provider receives rapid feedback on the administrative transaction submission. The direct connectivity system may automatically analyze transaction file attributes to determine one or more of many payers to which to send a transaction file, from one of many providers. Batch and singleton file transfer is supported for multiple file formats, optionally with secure file transfer.

Claims

1. A service provider data processing system comprising:

a communication interface;

memory comprising;

transaction files;

transaction file configuration data comprising configuration entries that associate claim file attributes with multiple payers;

payer connection data comprising payer communication addresses for the multiple payers; and

a transaction file submission program comprising transaction file attribute analysis instructions that determine a selected payer communication address in the payer connection data for an analyzed transaction file of the transaction files, and transmission instructions that initiate transfer of the analyzed transaction file to the selected payer communication address through the communication interface, thereby bypassing transaction file processing intermediaries; and

a processor coupled to the memory that executes the transaction file submission program.

2. The service provider data processing system of claim 1, where the memory further comprises a response acceptance program comprising:

response reception instructions that receive a response to the transfer of the analyzed transaction file from the selected payer communication address; and

response push instructions that configure the response for a practice management program in the service provider data processing system.

3. The service provider data processing system of claim 1, where the transaction file configuration entries comprise a filename entry and a payer identification entry.

4. The service provider data processing system of claim 1, where the transaction file configuration entries comprise a directory entry and a payer identification entry.

5. The service provider data processing system of claim 1, where the payer connection data comprises payer identification entries associated with the payer communication addresses.

6. The service provider data processing system of claim 1, further comprising an extensible markup language (XML) wrapper program that applies an XML wrapper to at least a portion of the analyzed transaction file.

7. The service provider data processing system of claim 1, further comprising an encryption program that applies an encryption to the analyzed transaction file.

8. The service provider data processing system of claim 1, where the memory further comprises a practice management program and where the transaction file submission program is integrated with the practice management program through a transaction submission program application programming interface.

9. The service provider data processing system of claim 8, where the practice management program is a physician'"'"'s office management and medical information system (POMIS) program.

10. A direct connectivity gateway that interacts with a practice management processing system that prepares administrative transaction files, the gateway comprising:

a communication interface;

a memory comprising;

payer connection data comprising payer communication addresses for multiple payers;

a file interface program comprising file transfer instructions that transfer transaction files to the direct connectivity gateway; and

a transaction file submission program comprising transaction file attribute analysis instructions that determine a selected payer communication address in the payer connection data for an analyzed transaction file of the claim files, and transmission instructions that initiate transfer of the analyzed transaction file to the selected payer communication address through the communication interface, thereby bypassing transaction file processing intermediaries; and

a processor that executes the transaction file submission program and the file interface program.

11. The gateway of claim 10, where the communication interface is a service provider local network interface connected to the practice management processing system.

12. The gateway of claim 10, where the transaction file attribute analysis instructions comprise filename attribute analysis instructions.

13. The gateway of claim 10, where the transaction file attribute analysis instructions comprise directory attribute analysis instructions.

14. The gateway of claim 10, further comprising an extensible markup language (XML) wrapper program that applies an XML wrapper to at least a portion of the analyzed transaction file.

15. The gateway of claim 10, where the practice management processing system and the gateway are located at a service provider.

16. A machine readable medium encoded with instructions that cause a service provider data processing system to perform a method comprising the acts of:

determining that an administrative transaction file has been prepared;

obtaining a selected file attribute of the transaction file;

reading payer connection data to determine a selected payer for the transaction file according to attribute data that associates the transaction file attributes, including the selected file attribute, with multiple payers, including the selected payer; and

initiating transmission of the transaction file to the selected payer of the multiple payers, thereby bypassing transaction file processing intermediaries.

17. The machine readable medium of claim 16, further comprising the acts of:

receiving a response from the selected payer to the transmission of the transaction file; and

configuring the response for a pre-determined practice management program.

18. The machine readable medium of claim 16, where the file attribute is a filename.

19. The machine readable medium of claim 16, where the file attribute is a file directory.

20. The machine readable medium of claim 16, where the payer configuration data comprises payer identification entries associated with payer communication addresses.

21. A machine readable medium encoded with instructions that cause a direct connectivity gateway to perform a method comprising the acts of:

connecting to a service provider data processing system through a communication interface;

determining that a transaction file has been prepared on the service provider data processing system;

transferring the transaction file to the direct connectivity gateway;

obtaining a selected file attribute of the transaction file;

reading payer connection data to determine a selected payer of multiple payers for the transaction file according to attribute data that associates file attributes, including the selected file attribute, with the multiple payers, including the selected payer; and

initiating transmission of the transaction file to the selected payer of the multiple payers, thereby bypassing transaction file processing intermediaries.

22. The machine readable medium of claim 21, where the act of connecting to the service provider data processing system comprises the act of connecting to a service provider data processing system co-located with the gateway.

23. The machine readable medium of claim 21, further comprising:

receiving a response from the selected payer to the transmission of the transaction file; and

configuring the response for a pre-determined claim management program.

24. The machine readable medium of claim 21, where the file attribute is a filename.

25. The machine readable medium of claim 21, where the file attribute is a file directory.

26. A machine readable medium encoded with instructions that cause a service provider data processing system to perform a method comprising the acts of:

automatically monitoring a service provider memory for a transaction file prepared by a provider;

obtaining a file attribute of the transaction file; and

switching the transaction file directly from the provider to a selected payer chosen from multiple payers, according to the file attribute, thereby bypassing transaction file processing intermediaries.

27. The machine readable medium of claim 26, further comprising the acts of:

receiving a response from the selected payer; and

automatically preparing the response for input by a practice management program.

28. The machine readable medium of claim 26, where the act of switching comprises reading payer connection data to associate the file attribute with the payer and initiating transmission of the transaction file.

29. The machine readable medium of claim 26, further comprising wrapping at least a portion of the transaction file with extensible markup language (XML) tags to obtain a wrapped transaction file for transmission.

30. The machine readable medium of claim 29, further comprising applying an encryption to the wrapped transaction file.

31. A machine readable medium encoded with instructions that cause a service provider data processing system to perform a method comprising the acts of:

automatically monitoring a service provider memory for a transaction file prepared by a provider;

obtaining a file attribute of the transaction file;

indexing the file attribute into attribute data comprising attribute identifiers associated with multiple payers to determine a selected payer;

determining a communication address for the selected payer of the multiple payers; and

transmitting the transaction file directly from the provider to the selected payer of the multiple payers by bypassing transaction file processing intermediaries, thereby bypassing transaction file processing intermediaries.

32. The machine readable medium of claim 31, further comprising the acts of:

receiving a response from the selected payer; and

automatically preparing the response for input by a practice management program.

33. The machine readable medium of claim 31, where the file attribute is a file name.

34. The machine readable medium of claim 31, where the file attribute is a file directory.

35. A machine readable medium encoded with instructions that cause a direct connectivity gateway to perform a method comprising the acts of:

automatically connecting to a service provider data processing system through a communication interface locally connected to the service provider data processing system;

transferring a transaction file to the direct connectivity gateway;

obtaining a file attribute of the transaction file;

indexing the file attribute into attribute data comprising attribute identifiers associated with multiple payers to determine a selected payer;

determining a communication address for the selected payer of the multiple payers; and

transmitting the transaction file directly from the provider to the selected payer by bypassing transaction file processing intermediaries, thereby bypassing transaction file processing intermediaries.

36. The machine readable medium of claim 35, further comprising:

receiving a response from the selected payer;

automatically preparing the response for input by a practice management program in the service provider data processing system; and

transferring the response to the service provider data processing system.

37. The machine readable medium of claim 36, where the act of preparing the response comprises determining a destination directory for the response, and where transferring the response comprises transferring the response to the destination directory on the service provider data processing system.

38. The machine readable medium of claim 36, where the act of preparing the response comprises determining a destination filename for the response, and where transferring the response comprises transferring the response to the destination filename on the service provider data processing system.