SYSTEM AND METHOD FOR IMPLEMENTING HEALTHCARE FRAUD COUNTERMEASURES

• US 20070168232A1
• Filed: 03/19/2007
• Published: 07/19/2007
• Est. Priority Date: 01/22/2003
• Status: Active Grant

• Current Assignee: Scott Kimmel
• Original Assignee: Scott Kimmel
• Inventors: Kimmel, Scott
• Granted Patent: US 7,421,399 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/06 Buying, selling or leasing transactions
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A method of discouraging healthcare fraud in conjunction with providing a health care service to a patient in which the patient provides a biometric signature. An event record is created where the event record creates an association between the biometric signature, a patient identifier, and location information indicating a location at which the biometric signature is obtained. The event record is stored in a central data store and can be later retrieved to verify the patient was present at the location.

Claims

1. A method of discouraging healthcare fraud comprising:

providing a health care service;

causing said patient to provide a biometric signature on a date and at a location where the health care service is provided;

capturing said biometric signature;

creating an event record that records said patient was at said location at a particular time and/or date, said event record comprising a patient identifier, said biometric signature, location information indicating said particular location at which said biometric signature is obtained;

transmitting said event record including said biometric signature to a computerized data store that is accessible by a payer entity; and

storing said event record in said computerized data store.

2. The method of claim 1 wherein said act of storing said event record is performed before said biometric signature is used to identify said patient receiving said healthcare services.

3. The method of claim 1 wherein said act of storing said event record is performed before said biometric signature is used to authenticate said person receiving said healthcare service.

4. The method of claim 1 wherein said healthcare service comprises a service that is reimbursable by a private insurance plan and/or a public program.

5. The method of claim 1 further comprising obtaining a biometric signature at least two times during said provision of health care services.

6. The method of claim 1 further comprising:

receiving a claim for reimbursement for said health care services;

retrieving one or more event records corresponding to said health care services from said data store;

matching said claim for reimbursement to an event record for a particular patient to determine whether said one or more event records contain location information indicating that said patient was at a suitable location for providing said health care services; and

authorizing financial reimbursement of said health care service based in part upon said determination that said patient was present at a location suitable for providing said health care service.

7. The method of claim 1 further comprising:

retrieving one or more records from said data store; and

performing a fraud detection process using said retrieved records.

8. The method of claim 1 wherein said biometric signature comprises a fingerprint scan record.

9. The method of claim 1 further comprising:

including within said event record an indication of consumable materials used during provision of said healthcare services.

10. The method of claim 1 further comprising:

including within said event record and indication of equipment used during provision of said healthcare services.

11. The method of claim 1 further comprising:

including within said event record an indication of procedures performed during said provision of said healthcare services.

12. The method of claim 1 wherein said location information comprises an identification code assigned to a heath care facility.

13. The method of claim 1 wherein said location information comprises a geocode.

14. The method of claim 1 wherein said location information comprises a network address of a computer used to obtain said biometric signature.

15. The method of claim 1 wherein said location information comprises a device address of a fingerprint scanner.

16. A biometric audit trail system comprising:

means for obtaining biometric information from a person at a particular location, said particular location being associated with a location identification;

a biometric record comprising said biometric information and said location identification;

a central storage system for storing said biometric record with a plurality of other biometric records; and

processes for retrieving biometric records at a later time from said central storage system to audit locations visited by particular persons.

17. The system of claim 16 further comprising processes operable to analyze said retrieved biometric records to identify patterns amongst a plurality of biometric records.

18. The system of claim 16 wherein said biometric record further comprises a timestamp indicating a time at which said biometric information was obtained.

19. A method of preventing fraud comprising:

providing a computerized biometric registration system at a physical location at which goods and/or services are provided to a person;

upon providing of the goods and/or services, obtaining a biometric reading from a person receiving the goods and/or services using said computerized biometric registration system; and

storing said biometric reading together said indicia of the physical location in a computerized database.

20. The method of claim 19 wherein said act of storing is performed before said biometric reading is used to identify said person receiving said goods and/or services.

21. The method of claim 19 wherein said act of storing is performed before said biometric reading is used to authenticate said person receiving said goods and/or services.

22. The method of claim 19 wherein said goods and/or services comprise medical treatment.

23. The method of claim 19 further comprising obtaining a biometric reading at least two times during said provision of goods and/or services.

24. An event record comprising:

a computer readable media configured to store said event record;

at least one biometric signature uniquely associated with a participant in an event;

location information indicating one or more locations at which said event occurred; and

at least one timestamp indicating a time at which said event occurred.

25. Claims management software implemented on a computer comprising:

an interface for receiving claim input reflecting information about a claim for reimbursement, wherein said claim input is related to health care services provided to an insured person;

processes for evaluating said claim input to determine whether payment of said claim is justified; and

an interface operable to receive information from an entity other than said insured or a provider of said health care services, wherein said information is related to said claim input indicating whether said insured person in fact received said health care services for which said claim for reimbursement relates.

26. Practice management software including processes executing in a computing device at a health care providers location comprising:

a patient interface driving a display device;

a biometric signature device coupled to said patient interface and providing biometric signature data to said patient interface;

processes executing in said computing device for causing said patient interface to prompt a patient to use said biometric signature device;

processes executing in said computing device for capturing said biometric signature data; and

processes executing in said computing device for communicating said biometric signature data together with information identifying said health care provider location to an external data processing service.

27. The practice management software of claim 26 further comprising a data cache coupled to said patient interface and said processes for communicating and operable to store biometric signature data such that said processes for communicating can operate asynchronously with respect to said processes for capturing said biometric signature data.

28. The practice management software of claim 26 wherein said biometric signature device comprises a fingerprint scanner.

29. The practice management software of claim 26 further comprising a user input device for entering user identification information.

30. A system for recording the location of a particular person at a particular place and time comprising:

a biometric signature device operable to capture a biometric signature of a particular person;

a clock generating an indication of a time at which said biometric signature was captured; and

a computerized interface configured to communicate said biometric signature and said indication of the time at which said biometric signature was captured for storage at a remote location.

31. The system of claim 30 further comprising:

location information stored within said system, wherein said interface is configured to communicate said location information together with said biometric signature and clock information for storage at a remote location.

32. Biometric event recording software including processes executing in a computing device at a health care provider'"'"'s location comprising:

a biometric signature device coupled to provide biometric signature data;

processes executing in said computing device for prompting a person to use said biometric signature device;

processes executing in said computing device for capturing said biometric signature data; and

processes executing in said computing device for communicating said biometric signature data that was provided at the health care provider'"'"'s location together with information identifying said health care provider location to an external data processing service.

33. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient received said health care service at a particular time and/or date, said event record comprising a patient identifier and said biometric signature, wherein said event record indicates the absence of phantom billing, wherein said event record is created using a computer system; and

transmitting said event record including said biometric signature to a computerized data store that is accessible by a payer entity.

34. The method of claim 33 further comprising capturing said biometric signature at least two times during said provision of health care services.

35. The method of claim 33 further comprising:

receiving a claim for reimbursement for said health care services;

determining whether said one or more event records indicate the absence of phantom billing; and

authorizing financial reimbursement of said health care service based in part upon said determination that said event record indicates the absence of phantom billing.

36. The method of claim 33 further comprising:

performing a fraud detection process using said event records.

37. The method of claim 33 further comprising:

including within said event record an indication of consumable materials used during provision of said healthcare services.

38. The method of claim 33 further comprising:

including within said event record and indication of equipment used during provision of said healthcare services.

39. The method of claim 33 further comprising:

including within said event record an indication of procedures performed during said provision of said healthcare services.

40. A method of discouraging healthcare fraud comprising:

providing a health care service at a particular location;

determining a patient ID for a patient;

creating an event record that records said patient was at said particular location to receive said health care service, said event record comprising the patient identifier and location information indicating said patient ID and said particular location at which said health care service is provided; and

transmitting said event record including said biometric signature to a computerized data store that is accessible by a payer entity; and

.

41. A method of discouraging healthcare fraud comprising:

causing said patient to provide a biometric signature at a health care service provider'"'"'s location

communicating information from said health care service provider to a payer entity wherein the healthcare provider provides reimbursement for healthcare services;

creating an event record that records said patient was at said health care service provider'"'"'s location at a particular time, said event record comprising a patient identifier, said biometric signature, information indicating said health care provider'"'"'s location at which said biometric signature is obtained and at which said health care service is provided.

transmitting said event record including said biometric signature to a computerized system that is accessible by a payer entity; and

authorizing reimbursement of costs associated with said health care service based in part upon said determination that said event record indicates the absence of phantom billing.

42. The method of claim 41 wherein said computerized system is accessible by a single payor entity.

43. The method of claim 41 further comprising:

executing claims management software processes by the payor entity to verify claims based upon the transmitted event record.

44. The method of claim 41 wherein said computerized system is accessible by multiple payer entities.

45. A method of discouraging healthcare fraud comprising:

providing a health care service;

causing said patient to provide a biometric signature on a date and at a location where the health care service is provided;

capturing said biometric signature;

creating an event record for each provided biometric signature, wherein the event record records said patient was at said location at a particular time and/or date, said event record comprising a patient identifier, said biometric signature, location information indicating said particular location at which said biometric signature is obtained;

transmitting said event record including said biometric signature to a computerized data store that is accessible by a payer entity; and

storing said event record in said computerized data store.