HEALTHCARE SYSTEM AND METHOD FOR RIGHT-TIME CLAIMS ADJUDICATION AND PAYMENT

• US 20070005403A1
• Filed: 06/30/2006
• Published: 01/04/2007
• Est. Priority Date: 07/01/2005
• Status: Active Grant

• Current Assignee: First Data Corporation (Fiserv Incorporated)
• Original Assignee: First Data Corporation (Fiserv Incorporated)
• Inventors: Bartlett, Robyn, Kennedy, Beverly
• Granted Patent: US 8,788,293 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/20 Point-of-sale [POS] network systems
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• 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 system and method for permitting real-time payment of healthcare charges from multiple sources of payment. A POS terminal is used to enter a patient ID and treatment code. A health insurance network receives the patient ID and treatment code and returns an estimated explanation of benefits (EOB) data packet that is used to display an EOB statement at the POS terminal, the display including information on a patient portion not covered by the health insurance plan. The EOB data packet is used to electronically process payment for the patient portion from a second payment source, such as an medical savings account (MSA), credit card account or banking account.

Claims

1. A system for providing right-time claim adjudication and payment for patient healthcare services, where payment may be made by multiple payer sources, the system comprising:

a point of sale (POS) device for use by a provider in entering patient information, including at least patient ID information and a healthcare treatment code for the patient healthcare services; and

a host for receiving the patient information from the POS device for submission as a healthcare claim to a first payer source, the host for also providing estimated explanation of benefits (EOB) information in response to the patient information, the estimated EOB information including at least information on any patient portion of a provider charge that is not to be paid by the first payer source;

whereby the patient may authorize payment of the patient portion on a real-time basis to the provider in response to the estimated EOB information.

2. The system of claim 1, wherein the estimated EOB information is displayed at the POS terminal in order for the patient to authorize payment of the patient portion.

3. The system of claim 2, wherein the estimated EOB information further includes information relating to a permitted charge corresponding to the treatment code.

4. The system of claim 1, wherein the patient authorizes payment of the patient portion from a second payment source.

5. The system of claim 4, wherein the second payment source is selected from a group consisting of a credit card account, debit card account, MSA, or a bank account.

6. The system of claim 5, wherein the host receives information on the second payment source and electronically posts the amount of the patient portion as a transaction against the second payment source.

7. The system of claim 5, wherein the host receives information on the second payment source, and wherein the second payment source is a credit card account and wherein authorization of payment is a reserve against a credit limit for the account.

8. The system of claim 6, wherein the estimated EOB information further includes information on a permitted charge corresponding to the patient information.

9. The system of claim 1, wherein first payer source provides final EOB information in response to the patient information and separate from the estimated EOB information, and wherein a patient portion in the separate EOB information is reconciled against the patient portion in the estimated EOB information.

10. The system or claim 1, wherein the host is operated by a third party transaction processing entity.

11. The system of claim 1, wherein the host is operated by the provider.

12. The system of claim 1, wherein the POS device displays information on at least one of the payment sources other than the first payment source, so that the other payment source may be selected for the patient portion, thereby permitting real-time payment of the patient portion by the selected payment source.

13. The system of claim 12, wherein the first payment source is a healthcare insurer, and wherein the selected other payment source is an MSA account.

14. The system of claim 12, wherein the first payment source is a healthcare insurer, and wherein the selected other payment source is a financial account maintained by the patient.

15. The system of claim 14, wherein the financial account maintained by the patient is a credit card account.

16. The system of claim 15, wherein the financial account maintained by the patient is a banking account.

17. A method for making payment on a charge from a provider of healthcare services, wherein the services are subject to a healthcare plan administered by a first payer, and wherein a patient portion of the charge may not be covered by the healthcare plan, and wherein a second payer may be used for the patient portion, the method comprising:

providing a healthcare provider system at the provider location for healthcare services, the provider system for receiving a patient ID and a treatment code identifying healthcare services provided to the patient, and the provider system for identifying the first payer;

electronically preparing a claim at the provider system for the first payer system, the claim including the patient ID and the treatment code;

generating estimated EOB data in response to the claim, and transmitting the estimated EOB data to the provider system, the estimated EOB data representing at least the patient portion;

displaying the estimated EOB data at the provider system so that the patient may authorize payment from the second payer for the patient portion; and

electronically submitting an authorization for payment from the provider system to a second payer system, in order to process real-time payment from the second payer at the time that healthcare services are provided to the patient.

18. The method of claim 17, wherein the patient ID is received at the provider system by reading a presentation instrument.

19. The method of claim 18, further comprising:

subsequently receiving non-estimated EOB data from the first payer; and

reconciling the non-estimated EOB data against the estimated EOB data.

20. The method of claim 17, wherein a third party processing entity generates the estimated EOB data, submits the claim to the first payer system, and processes authorization for payment to the second payer system.

21. The method of claim 17, wherein the healthcare plan is a high deductible plan.

22. A system for making payment for patient healthcare services to a provider of such services, where payment may be made by multiple payer sources, including a first payer to whom a health care claim is submitted and a second payer maintaining an account on behalf of the patient that may be used for amounts not paid by the first payer, the system comprising:

a point of sale (POS) device for use by the provider in entering data, including at least a patient identification and a treatment code; and

a healthcare network linked to the POS terminal and to the second payer, the healthcare network for;

receiving data entered at the POS terminal and in response to the received data electronically transmitting a healthcare claim to the first payer source and to an estimating system;

receiving from the estimating system an estimated explanation of benefits (EOB) message in response to the healthcare claim, the estimated EOB message including at least (a) information on a permitted charge corresponding to the treatment code and (b) information relating to any patient portion of such permitted charge that is not to be paid by the first payer; and

posting an electronic transaction against the second payer account in response to receipt of the patient portion information, so that real-time payment of the patient portion to the provider may be made after the estimated EOB message is received by the healthcare network.

23. The system of claim 22, wherein:

the POS terminal receives information relating to the second payer account at the time the patient receives healthcare services from the provider;

the healthcare network assigns a reference identifier associated with the second payer account and associates the reference identifier with the healthcare claim; and

the healthcare network uses the reference number to identify the second payer account when the estimated EOB is received from the first payer, in order to post a transaction against the second payer account.

24. The system of claim 23, wherein the healthcare network includes a host computer linked to the POS terminal and to the second payer.

25. The system of claim 24, wherein the healthcare network subsequently receives a non-estimated EOB message from the first payer, and where a patient portion of the non-estimated EOB message is reconciled against the patient portion of the estimated EOB message

26. The system of claim 24, wherein the healthcare network includes the estimating system, and wherein the healthcare network is a third party processing entity.