Healthcare transaction system and method for automated healthcare claim resolution and workflow management

• US 20060271412A1
• Filed: 05/27/2005
• Published: 11/30/2006
• Est. Priority Date: 05/27/2005
• Status: Abandoned Application

• Current Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Original Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Inventors: Yurjevich, Steven J., Corzine, Matthew M., Brown, Darby W., Sohr, James W.
• Application Number:
  US11/140,216
• Publication Number:
  US 20060271412A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/06375 Prediction of business process outcome or impact based on a proposed change
• 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 50/182 Alternative dispute resolution
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A scalable healthcare claim resolution and workflow management system is provided which resolves healthcare claim discrepancies and disputes among multiple healthcare payers and providers. The system can also be used to communicate and track claims within a single organization. The claim resolution system facilitates communication between parties while maintaining an inventory and tracking claim disputes within the system. The system standardizes the inefficient and disparate systems found in the art.

Claims

1. A method for resolving healthcare claims, the method comprising the steps of:

providing an electronic portal to be accessed by at least a first end user;

referring a claim dispute to be viewed as a claim dispute record via the portal;

maintaining a secure private environment for communication between any claim resolution participants and for accessing the portal;

transmitting the claim dispute record and end user communication via the electronic portal to at least a second end user;

tracking the claim dispute.

2. The method of claim 1, further comprising the step of storing the claim dispute record in a claim dispute inventory.

3. The method of claim 1, further comprising the step of promoting the claim dispute record through a hierarchy of pre-defined statuses.

4. The method of claim 1, wherein the step of tracking the claim dispute record includes stamping the record with time and date indicators.

5. The method of claim 1, further comprising the step of stamping a claim dispute record to record actions enacted on the claim dispute.

6. The method of claim 1, wherein the step of tracking the claim dispute further comprises the step of recording both modifications to the claim dispute record and identification information for the user making the modifications.

7. The method of claim 1, further comprising the step of restricting access to the portal to authorized end users.

8. The method of claim 1, further comprising the step of storing information concerning a claim dispute in a database, the database being accessible in real-time to parties with access to the portal.

9. The method of claim 1, wherein the step of transmitting a claim dispute record via the portal includes transmissions to at least one third-party participant.

10. The method of claim 1, further comprising the step of defining allowable actions in a claim dispute.

11. The method of claim 10, further comprises the step of stamping the claim dispute record when an end user selects at least one of the defined actions.

12. The method of claim 11, further comprising the step of identifying in the claim dispute record the end user acting in the claim dispute.

13. The method of claim 10, further comprising the step of incorporating a rules and glossary appendage to a claim dispute record, the appendage at least partially dictating actions allowed by the various end users.

14. The method of claim 1, further comprising the step of customizing a view of the claim dispute record that is displayed via the portal.

15. The method of claim 14, wherein the view of the claim dispute record is customized to account for contractual agreements between at least the first and second end users.

16. The method of claim 14, wherein the view of the claim dispute record is customized to account for the role of the end user viewing the dispute record.

17. The method of claim 1, further comprising the step of appending electronic document images to a claim dispute record, the documentation being accessible via the portal.

18. The method of claim 1, further comprising the step of copying to a claim dispute record identities of all third parties working on the subject claim dispute.

19. The method of claim 1, wherein the portal provides a location for a claim record to be viewed with full disclosure of the claim record to each end user involved in the claim dispute.

20. The method of claim 1, further comprising the step of settling a claim dispute by forwarding information in support of a settlement offer via the portal between at least first and second end users.

21. The method of claim 20, further comprising the step allowing a second end user to modify a forwarded settlement offer, said modified offer viewable by each end user via the portal.

22. The method of claim 1, further comprising the step of automatically populating legal documents related to a claim dispute with the documents to be shared by multiple end users.

23. The method of claim 1, further comprising reporting and analyzing data from the disputed claim inventory.

24. A method for resolving healthcare claims, the method comprising the steps of:

providing an electronic portal to be accessed by end users;

creating at least one claim dispute record in a claim dispute inventory database, said inventory and said claim dispute record viewable via the portal;

forwarding that claim to an identified individual at a third party for resolution;

verifying receipt of claim by third party;

accessing the portal using secure electronic communication;

progressing the claim dispute record through a hierarchy of pre-defined statuses when the one or more users select predefined actions displayed by the portal; and

tracking the claim dispute record.

25. The method of claim 24, further comprising the step stamping the record with time and date indicators when the one or more users select an action.

26. The method of claim 24, further comprising the step of recording user selected actions and the identity of the user taking the selection action in the claim dispute record.

27. The method of claim 24, further comprising the step of restricting access to the portal to authorized end users.

28. The method of claim 24, further comprising the step of customizing a view of the claim dispute record that is displayed via the portal.

29. The method of claim 28, wherein the view of the claim dispute record is customized to account for contractual agreements between at least first and second end users.

30. The method of claim 28, wherein the view of the claim dispute record is customized to account for the role of the end user viewing the dispute record.

31. The method of claim 24, further comprising the step of appending electronic documentation to a claim dispute record, the documentation being accessible via the portal.

32. The method of claim 24, wherein the portal provides a location for a claim record to be viewed with full disclosure of the claim record to each end user involved in the claim dispute.

33. The method of claim 24, further comprising the step of settling a claim dispute by forwarding information in support of a settlement offer via the portal from a first end user to a second end user.

34. The method of claim 33, further comprising the step of allowing an end user to modify the settlement offer, said modified offer viewable by end users via the portal.

35. A system for resolving healthcare claims, the system comprising:

an electronic portal,

a database connected to said portal,

at least one computer in electrical connection with said electronic portal,

a claims record stored in said database to be viewed via said portal, and

wherein said at least one computer provides views and action options to an end user so that said claims record is viewable and modifiable via said views and options in said portal.

36. The system of claim 35, further comprising a claim dispute inventory containing multiple claims records.

37. The system of claim 36, further comprising a report based upon information stored in said claim dispute inventory.

38. The system of claim 35, further comprising date and time stamps placed within a claims record when a claim record is modified using said pre-defined options.

39. The system of claim 37, further comprising an identification stamp in the claim dispute record that contains identification information for the end user acting in the claim dispute.

40. The system of claim 35, wherein said database contains a rules and glossary appendage to a claim dispute record, the appendage at least partially dictating actions allowed by the various end users.

41. The system of claim 35, wherein said view comprises a customizable view of the claim dispute record that is displayed via the portal.

42. The system of claim 41, wherein the view of the claim dispute record is customized to account for the role of the end user viewing the dispute record.

43. The system of claim 35, further comprising appendices stored in said database, said appendices including electronic documentation related to a specific claim dispute record, said documentation being accessible via the portal.

44. The system of claim 35, further comprising statutory rules stored in said database, said statutory rules being applicable to one or more claim dispute records, said statutory rules being accessible via the portal.