System and method for managing account receivables

• US 20060041487A1
• Filed: 03/03/2003
• Published: 02/23/2006
• Est. Priority Date: 02/19/2003
• Status: Active Grant

• Current Assignee: Medusind Inc.
• Original Assignee: Avisena Incorporated
• Inventors: Pacheco, Allan, Stephens, Jihad, Santalo, Albert, Sardinas, Ben Andrew
• Granted Patent: US 7,752,096 B2
• Time in Patent Office: Days
• US Class Current: 705/30
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 40/12 Accounting

Abstract

A system for managing account receivables is provided. The system comprises a rules module or engine for receiving at least one encounter from a first party and for assessing the at least one encounter based on rules associated with a payer; and a transactions module or engine for outputting at least one claim to the payer based on the rule module'"'"'s assessment of the at least one encounter.

Claims

10. A method for managing account receivables, comprising:

inputting at least one encounter into a capture screen;

transforming the at least one encounter into at least one transaction;

posting the at least one transaction to a transaction table;

pulling at least one charge from the at least one transaction;

assembling the at least one charge;

comparing the at least one charge based on client billing parameters and payer parameters;

building at least one batch of the at least one charge based on payer and/or media; and

outputting the at least one batch to at least one payer.

11. The system of claim 10 wherein the at least one batch is outputted to at least one payer electronically or by mail based on a global set of payer/carrier parameters kept within a global insurance library.

12. The system of claim 10 further comprising:

receiving a remittance from the at least one payer, the remittance comprising a payment or denial of the at least one claim;

posting the remittance as at least one denial to a reimbursement management engine if the remittance is a denial and to a transaction table if the remittance is a payment;

creating an incident associated with the at least one denial; and

sending the at least one denial to a reimbursement management engine or collection work.

13. A method for managing reimbursement incidents, comprising:

receiving at least one incident; and

working the at least one incident based on who generated the incident, the type of incident, the type of payer, the incident reason, the available resources for working the at least one incident.

14. The method of claim 13 wherein incident comprises at least one a no response, a denial, an underpayment, a pended claim, a temporary denial, or any other type of collection incident.

15. The method of claim 13 where the incident is a denied or ignored, or other type.

16. A method for managing accounts receivables, comprising:

posting an encounter to a transaction table;

processing the encounter to determine likelihood of receiving payment;

presenting encounter to a payer;

receiving a remittance from the payer; and

posting the remittance to the transaction table.

17. A method for processing collection incidents, comprising:

receiving at least one aged collection incident;

receiving at least one new collection incident;

grouping the at least one aged collection incident and the at least one new collection incident in a desired order; and

working the at least one aged collection incident and the at least one new collection incident in the desired order.

18. A method for classifying accounts receivable, comprising:

evaluating information on a receivable;

determining the payer associated with the receivable;

determining past payment patterns of the payer; and

aging the account receivable.

19. The method of claim 18 where the receivable comprises a service line or group of charges.

20. The method of claim 18 where aging occurs according to the past payment patterns of the payer.

21. The method of claim 18 where aging occurs according to predetermined parameters.

22. The method of claim 20 where the predetermined parameters comprise a number of days.

23. A method for validating incoming encounters, comprising:

receiving an encounter from a provider, the encounter containing information related to services rendered to a patient;

evaluating the information contained in the encounter based on specified rules;

determining whether the encounter is invalid; and

permitting the encounter to be amended if the encounter is invalid.

26. The method of claim 23 where the step of evaluating comprises at least one of:

evaluating the service lines individually, then against other service lines within the encounter, against the encounter itself, against the history of the patient, against the treatment plan(s) for the patient, and the patterns or requirements of the payer.

24. The invalid encounter is invalid because it is not likely to get paid.

25. The invalid encounter is invalid because the procedure(s) could not have been performed on the patient and/or the diagnosis(s)could not have been reached at the time of the encounter.

27. A method for valuing a service line or charge, comprising:

receiving at least one encounter from a provider;

posting the encounter as a service line or charge;

assigning a value to the service line or charge based on reimbursement information for a payer and/or provider.

28. The method of claim 27 wherein the reimbursement information for a payer and/or provider comprises contract information between that provider and payer, payment pattern defined by payer or region, and/or a reasonable and/or customary amount.

29. A method for retrieving and posting reimbursement information from a payer, comprising:

receiving at least one remittance from a payer;

determining the type of remittance;

validating and balancing the remittance;

adding additional information relating to the remittance to enhance collection;

posting the remittance, including all payments, denials, comments, remarks, memos, adjustments, instructions for subsequent payment, and any other information useful for collection; and

reconciling and/or reassigning any outstanding balances based on the remittance.

30. A method for creating and maintaining a global insurance library, comprising:

identifying if a new insurance information is encountered;

creating the new insurance;

maintaining insurance information in the library;

queuing the new insurance;

reviewing the new insurance information to ensure it is not a duplicate, capturing the new insurance information; and

merging the new insurance information to the global insurance library to include in progress work that references reviewed insurance information.

1. A system for managing account receivables, comprising:

a rules module or engine for receiving at least one encounter from a first party and for assessing the at least one encounter based on rules associated with a payer; and

a transactions module or engine for outputting at least one claim to the payer based on the rule module'"'"'s assessment of the at least one encounter.

2. The system of claim 1 where in the rule module'"'"'s assessment comprises posting the at least one encounter to a transaction table.

3. The system of claim 1 wherein the rules module or engine rejects the at least one encounter if it does not comply with the rules associated with the payer.

4. The system of claim 1 further comprising a remittance processing module or engine for receiving and processing at least one remittance from the payer.

5. The system of claim 4 wherein the remittance processing module or engine further determines, among other things, whether an underpayment incident has occurred.

6. The system of claim 5 wherein the at least one remittance comprises at least one of a payment and a denial.

7. The system of claim 1 further comprising a nightly aging module or engine for aging accounts receivables on a nightly basis.

8. The system of claim 1 further comprising a reimbursement management module or engine for, among other things, organizing collection items into an efficient configuration.

9. The system of claim 8 wherein the reimbursement management module or engine assess at least one of a denial incident, a no-response incident, an underpayment incident, and a patient past due incident.

31. The method of claim 30 wherein the new insurance is encountered during at least one of:

patient registration and claim assembly and submission.

32. The method of claim 30 wherein the new insurance is encountered by at least one of:

a rules engine or system, a remittance processing engine or system;

a reimbursement management engine or system; and

a reporting stage.

32-1. The method of claim 30 wherein the new insurance information comprises:

address information, contact information, transmission media that contains information on the plan, the media on which you can transmit information to payer, what type of claim can be transmitted to payer, demographic and contact information on the payer, relationship between the payer and carrier.