Fraud, abuse, and error detection in transactional pharmacy claims
First Claim
1. A computer-implemented method for processing benefits payment claims for prescription medicine, comprising operations of:
- receiving pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient-drug combination;
for each claim, performing operations comprising;
performing computer-driven statistical analysis of predefined aspects of a claims history for the specified patient-drug combination in relation to a history of claims paid by the pharmacy benefits claims payor involving a multiplicity of different patients and drugs;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator.
1 Assignment
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Accused Products
Abstract
A computer-implemented approach for processing benefits payment claims for prescription medicine, with these operations. Receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient. For each claim and its specified patient, performing operations including the following. Performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors: claims history for the patient, the claim, medical history of the patient. Generating an indicator of predicted legitimacy by scoring results of the statistical analysis. Providing an output of at least one of the following: the indicator, payment advice prepared by applying predefined criteria to data including the indicator.
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Citations
22 Claims
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1. A computer-implemented method for processing benefits payment claims for prescription medicine, comprising operations of:
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receiving pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient-drug combination;
for each claim, performing operations comprising;
performing computer-driven statistical analysis of predefined aspects of a claims history for the specified patient-drug combination in relation to a history of claims paid by the pharmacy benefits claims payor involving a multiplicity of different patients and drugs;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator.
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2. A computer-implemented method for processing benefits payment claims for prescription medicine, comprising operations of:
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receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient;
for each claim and its specified patient, performing operations comprising;
performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors;
claims history for the patient, the claim, medical history of the patient;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator. - View Dependent Claims (3, 4, 5, 6, 7, 8, 9, 10)
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11. A computer-driven apparatus to process payment claims for prescription medicine, comprising:
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an interface receiving pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient-drug combination;
a computer-driven analysis module programmed to perform operations for each claim, comprising;
performing computer-driven statistical analysis of predefined aspects of a claims history for the specified patient-drug combination in relation to a history of claims paid by the pharmacy benefits claims payor involving a multiplicity of different patients and drugs;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator.
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12. A computer-driven apparatus to process payment claims for prescription medicine, comprising:
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interface means for receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient;
computer-driven analysis means for performing operations for each claim and its specified patient, comprising;
performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors;
claims history for the patient, the claim, medical history of the patient;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator.
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13. A computer-driven apparatus to process prescription payment claims, comprising:
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at least one interface to receive pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim including specification of a patient;
first digital data storage containing a compiled history of past claims paid by one or more pharmacy benefits claims payors;
second digital data storage containing multiple schemas each defining a condition as to one of the following;
patient claims history, payment claim, patient medical history;
a metrics engine programmed to compute metrics by applying the schemas to data of at least one of the following in conjunction with a patient;
patient claims history, payment claim, patient medical history, bulk data;
a baseline engine to receive metrics computed for substantially all patients in the compiled history and produce baseline data comprising a statistical analysis of the received metrics in relation to the bulk data;
scoring engine programmed to process a claim received at the interface by performing operations comprising;
receiving metrics computed for a patient specified by the received claim;
statistically analyzing the received metrics against the compiled history;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator.
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14. A computer-driven apparatus to process payment claims for prescription medicine, comprising:
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an interface receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient;
a computer-driven analysis module programmed to perform operations for each claim and its specified patient, comprising;
performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors;
claims history for the patient, the claim, medical history of the patient;
generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
providing an output of at least one of the following;
the indicator, payment advice prepared by applying predefined criteria to data including the indicator. - View Dependent Claims (15, 16, 17, 18, 19, 20, 21, 22)
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Specification