Reimbursement claim processing simulation and optimization system for healthcare and other use

• US 20060106653A1
• Filed: 11/18/2005
• Published: 05/18/2006
• Est. Priority Date: 11/18/2004
• Status: Abandoned Application

• Current Assignee: Siemens Medical Solutions Health Services Corporation (Siemens AG)
• Original Assignee: Siemens Medical Solutions Health Services Corporation (Siemens AG)
• Inventors: Lis, Ellen R.
• Application Number:
  US11/282,458
• Publication Number:
  US 20060106653A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 20/10 specially adapted for electronic funds transfer [EFT] systems; specially adapted for home banking systems
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A system permits a healthcare provider to perform flexible, efficient, and timely multiple analyses of managed care organization (MCO) contracts, over a large database of historical information, to provide associated profitability information. An interface processor receives data representing multiple, different financial claims for reimbursement based on multiple, different predetermined reimbursement formulae. A source of data represents multiple calculable expressions. A repository includes data associating a particular calculable expression with multiple, different reimbursement formulae, and data associating particular financial claim data with particular reimbursement formulae. A data processor uses the repository to identify financial claim data of the data representing multiple different financial claims associated with particular reimbursement formula, and to initiate execution of a procedure comprising the particular calculable expression, derived from the source, to provide calculated data for use in determining reimbursement based on different reimbursement formulae.

Claims

11-1. A system according to claim 1, wherein

the data associating a particular calculable expression with a plurality of different reimbursement formulae and the data associating particular financial claim data with particular reimbursement formulae, is stored within tables in the at least one repository.

13. A method for financial claim reimbursement, comprising the steps of:

receiving data representing a plurality of different financial claims for reimbursement based on a plurality of different predetermined reimbursement formulae;

receiving a plurality of calculable expressions;

providing data associating a particular calculable expression with a plurality of different reimbursement formulae;

providing data associating particular financial claim data with particular reimbursement formulae;

using the at least one repository in identifying financial claim data of the data representing a plurality of different financial claims associated with particular reimbursement formula; and

initiating execution of a procedure comprising the particular calculable expression derived from the source to provide calculated data for use in determining a reimbursement value based on different reimbursement formulae.

14. A method according to claim 13, further comprising the step of:

initiating concurrent execution of procedures comprising the different reimbursement formulae.

15. A system according to claim 13, further comprising the step of:

initiating concurrent execution of procedures comprising the particular calculable expression to provide calculated data for use in determining a reimbursement value based on different reimbursement formulae.

16. A system according to claim 13, further comprising the step of:

deriving the plurality of calculable expressions by decomposing the plurality of different predetermined reimbursement formulae into component calculable expressions.

17. A system according to claim 13, further comprising the step of:

automatically decomposing the plurality of different predetermined reimbursement formulae into component calculable expressions by parsing formulae and using character matching.