Computerized system and methods for adjudicating and automatically reimbursing care providers

• US 20060265250A1
• Filed: 01/06/2006
• Published: 11/23/2006
• Est. Priority Date: 01/06/2005
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Patterson, Neal L.
• Granted Patent: US 7,881,950 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate. The method further includes the steps of accessing a second knowledge base containing at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine if the care provided is medically appropriate. Also, the method includes determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.

Claims

1. A method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:

receiving a number of transactions from a number of providers, each transaction including a number of clinical event details documented by a care provider;

accessing payer information for a number of payers;

for each transaction, determining a reimbursement amount based on the clinical event details for a first payer; and

for each transaction, automatically initiating reimbursement of the care provider by the first payer.

2. The method according to claim 1, further comprising:

for each transaction, determining a reimbursement amount based on the clinical event detail for a second payer.

3. The method according to claim 2, wherein the second payer is a consumer.

4. The method according to claim 3, wherein the reimbursement from the second payer is from a health savings account.

5. The method according to claim 1, further comprising the step of determining whether the transaction is eligible for reimbursement by the first payer.

6. The method according to claim 1, the step of determining a reimbursement amount further comprises accessing a first knowledge base including at least one option for providing medically appropriate care, and selectively performing analysis of the clinical data elements of the transaction against the at least one option to determine if the care provided is medically appropriate.

7. The method according to claim 6, wherein the clinical options consist of guidelines and standards.

8. The method according to claim 6, the step of determining a reimbursement level further comprises accessing a second knowledge base including at least one criterion for assessing quality of care, and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine the quality of care.

9. The method according to claim 1, further comprising reimbursing the provider in real-time.