Method and system for adjudicating claims in a health service environment

• US 20070255590A1
• Filed: 06/09/2006
• Published: 11/01/2007
• Est. Priority Date: 04/28/2006
• Status: Active Grant

• Current Assignee: MDI Technologies, Inc. (ResMed Incorporated)
• Original Assignee: Medical Developments International Ltd., Inc.
• Inventors: Green, Jason Reinis, Wood, Raymond Michael, Snyder, Robert John
• Granted Patent: US 8,121,864 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/109 Time management, e.g. calendars, reminders, meetings or time accounting
• 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

Methods and systems for adjudicating claims in health services environments are presented. An exemplary method for processing service provider claims for payment includes receiving a claim for payment, automatically identifying candidate appointments from a plurality of scheduled appointments based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments, analyzing the candidate appointments to determine whether to flag the received claim for resolution, and presenting the received claim for payment when at least one of the candidate appointments corresponds to the received claim. Optionally, the method includes automatically identifying already processed claims based on a degree of similarity between service information associated with the already processed claims and the service information associated with the received claim, analyzing the identified already processed claims to determine whether the received claim is a duplicate claim, and flagging potentially duplicate claims for resolution.

Claims

1. A method for processing service provider claims for payment, comprising:

receiving a claim for payment;

automatically identifying candidate appointments from a plurality of scheduled appointments based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments;

analyzing the candidate appointments to determine whether to flag the received claim for resolution; and

presenting the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

2. The method of claim 1, wherein the step of analyzing the candidate appointments comprises displaying the candidate appointments for review by an adjudicator, wherein the adjudicator determines whether to flag the received claim for resolution.

3. The method of claim 2, wherein the step of displaying the candidate appointments for review by an adjudicator comprises displaying the candidate appointments according to respective degrees of similarity to the received claim.

4. The method of claim 2, wherein the step of displaying the candidate appointments for review by an adjudicator comprises displaying the candidate appointments for review by an adjudicator when none of the candidate appointments directly corresponds to the received claim.

5. The method of claim 1, wherein the step of analyzing the candidate appointments comprises automatically flagging the received claim for resolution when none of the candidate appointments corresponds to the received claim.

6. The method of claim 1, further comprising:

automatically identifying already processed claims based on a degree of similarity between service information associated with the already processed claims and the service information associated with the received claim;

analyzing the identified already processed claims to determine whether the received claim is a duplicate claim; and

flagging potentially duplicate claims for resolution.

7. The method of claim 6, wherein the step of analyzing the identified already processed claims comprises automatically determining whether the received claim is potentially a duplicate claim.

8. The method of claim 6, wherein the step of analyzing the identified already processed claims comprises displaying the identified already processed claims for review by an adjudicator, wherein the adjudicator determines whether the received claim is a duplicate claim.

9. The method of claim 1, further comprising routing flagged claims to at least one trouble shooter for resolution.

10. A recording medium on which the method for processing service provider claims for payment as claimed in claim 1 is recorded as a program code that can be executed by a computer.

11. A method for processing service provider claims for payment, comprising:

receiving a claim for payment;

storing appointment information associated with a plurality of scheduled appointments and service information associated with the received claim;

automatically identifying candidate appointments from the scheduled appointments based on a degree of similarity between the service information associated with the received claim and the appointment information associated with the scheduled appointments; and

presenting the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

12. The method of claim 11, further comprising analyzing the candidate appointments to determine whether to flag the received claim for resolution.

13. A system for processing service provider claims for payment, comprising:

an intake module configured to receive a claim for payment;

a storage module configured to store appointment information associated with a plurality of scheduled appointments and service information associated with the received claim; and

an adjudication module configured to automatically identify candidate appointments from the scheduled appointments based on a degree of similarity between the service information associated with the received claim and the appointment information associated with the scheduled appointments, wherein the adjudication module is configured to present the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

14. The system of claim 13, wherein the adjudication module is configured to analyze the candidate appointments to determine whether to flag the received claim for resolution.

15. The system of claim 14, wherein the adjudication module is configured to automatically flag the received claim for resolution when none of the candidate appointments corresponds to the received claim.

16. The system of claim 14, further comprising a display device configured to display the candidate appointments for review by an adjudicator, wherein the adjudicator determines whether to flag the received claim for resolution.

17. The system of claim 16, wherein the display device is configured to display the candidate appointments for review by an adjudicator when none of the candidate appointments directly corresponds to the received claim.

18. A system for processing service provider claims for payment, comprising:

means for receiving a claim for payment; and

means for automatically identifying candidate appointments from a plurality of scheduled appointments based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments,

wherein the identifying means is configured to analyze the candidate appointments to determine whether to flag the received claim for resolution and present the received claim for payment when at least one of the candidate appointments corresponds to the received claim.