MEDICAL CLAIMS FRAUD PREVENTION SYSTEM INCLUDING PATIENT CALL INITIATING FEATURE AND ASSOCIATED METHODS

• US 20100332252A1
• Filed: 07/08/2010
• Published: 12/30/2010
• Est. Priority Date: 07/28/2005
• Status: Active Grant

• Current Assignee: Beraja IP LLC
• Original Assignee: IBEZA, LLC
• Inventors: Beraja, Victor, Beraja, Esther, Beraja, Matilde, Beraja, Roberto, Beraja, Isidoro
• Granted Patent: US 8,392,211 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A medical claim fraud prevention system includes a first controller positioned at a medical facility and a second controller positioned at a patient information collection center and adapted to be in communication with the first controller. The first controller may transmit a first signal to the second controller responsive to an occurrence of a predetermined event. The second controller may initiate contact with a patient via the patient'"'"'s mobile phone in response to the first signal revived from the first controller, and the patient may be prompted to enter predetermined information to verify their location. The second controller may transmit an indication to the first controller in response to the first signal received from the first controller regarding whether the patient is within a predetermined vicinity of the medical facility based on the predetermined information entered by the patient to verify their location.

Claims

1. A medical claim fraud prevention system comprising:

a first controller positioned at a medical facility;

a second controller positioned at a patient information collection center and adapted to be in communication with the first controller;

wherein the first controller sends a first signal to the second controller responsive to an occurrence of a predetermined event;

wherein the second controller initiates contact with a patient via the patient'"'"'s mobile telephone in response to the first signal received from the first controller;

wherein the patient is prompted to enter predetermined information to verify their location; and

wherein the second controller transmits an indication to the first controller in response to the first signal received from the first controller regarding whether the patient is within a predetermined vicinity of the medical facility based on the predetermined information entered by the patient to verify their location.

2. A system according to claim 1 wherein the patient is assigned a patient information unit having predetermined patient information associated therewith;

and wherein the predetermined event is reading information from the medical insurance information unit.

3. A system according to claim 2 wherein the first controller is a patient information unit reader adapted to read the predetermined patient information associated with the patient information unit.

4. A system according to claim 1 wherein a medical software system in communication with the first controller is used by a medical professional at the medical facility;

wherein the medical professional is prompted to enter information relating to the patient using the medical software system; and

wherein the predetermined event is entry of the information relating to the patient using the medical software system.

5. A system according to claim 1 wherein a billing system is used at the medical facility to bill for medical services provided to the patient;

and wherein the predetermined event is use of the billing system with respect to the patient.

6. A system according to claim 1 wherein the medical facility is at least one of a doctor'"'"'s office, a hospital, a pharmacy, a therapy center, a medical laboratory, a medical clinic, a rehabilitation facility, a dialysis unit, an outpatient center, an assisted care living facility, an emergency room and a nursing home.

7. A system according to claim 1 wherein the patient information collection center is associated with processing health insurance claims.

8. A system according to claim 1 wherein the signal transmitted from the first controller to the second controller includes information relating to a claim for reimbursement relating to medical services being provided to the patient at the medical facility.

9. A system according to claim 8 wherein the second controller transmits a signal to the first controller including an indication of whether or not the claim is a valid claim based on the indication of whether the patient is within the predetermined vicinity of the medical facility.

10. A system according to claim 1 wherein the predetermined information that the patient is prompted to enter is a personal identification number.

11. A system according to claim 1 wherein the predetermined information that the patient is prompted to enter is pressing a number on the telephone in response to a question presented to the patient.

12. A system according to claim 1 wherein the predetermined information that the patient is prompted to enter is a verbal response to a question presented to the patient.

13. A system according to claim 1 further comprising a backup locating system that is activated to perform a predetermined action based on a predetermined backup event.

14. A system according to claim 13 wherein the predetermined backup event that activates the backup locating system is an indication from the second controller that the patient is not within the predetermined vicinity of the medical facility based on the predetermined information entered by the patient to verify their location.

15. A system according to claim 13 wherein the predetermined action is at least one of calling the patient'"'"'s mobile telephone and speaking with the patient to determine the location of the patient, and providing a notification to the medical facility including a request that the patient contact the patient information collection center to verify the patient'"'"'s location.

16. A system according to claim 13 wherein the predetermined action is calling the medical facility and requiring the patient to verify their location using a predetermined patient identifier.

17. A system according to claim 13 wherein the predetermined action is calling the medical facility and speaking with the patient, and requiring the patient to verify their location using a predetermined patient identifier.

29. A method according to claim 13 wherein the predetermined information that the patient is prompted to enter is a verbal response to a question presented to the patient.

18. A method of preventing medical claim fraud, the method comprising:

transmitting a first signal from a first controller positioned at a medical facility to a second controller positioned at a patient information collection center responsive to an occurrence of a predetermined event, wherein the second controller is adapted to be in communication with the first controller;

initiating a telephone call to a patient'"'"'s mobile phone in response to the first signal received from the first controller;

prompting a patient to enter predetermined information to verify their location; and

transmitting an indication from the second controller to the first controller in response to the first signal received from the first controller of whether the patient is within a predetermined vicinity of the medical facility based on the predetermined information entered by the patient to verify their location.

19. A method according to claim 18 wherein the patient is assigned a patient information unity having predetermined patient information associated therewith;

and wherein the predetermined event is reading information from the medical insurance information unit.

20. A method according to claim 19 wherein the first controller is a patient information unit reader adapted to read the predetermined patient information associated with the patent information unit.

21. A method according to claim 18 wherein a medical software system in communication with the first controller is used by a medical professional at the medical facility;

wherein the medical professional is prompted to enter information relating to the patient using the medical software system; and

wherein the predetermined event is entry of the information relating to the patient using the medical software system.

22. A method according to claim 18 wherein a billing system is used at the medical facility to bill for medical services provided to the patient;

and wherein the predetermined event is use of the billing system with respect to the patient.

23. A method according to claim 18 wherein the medical facility is at least one of a doctor'"'"'s office, a hospital, a pharmacy, a therapy center, a medical laboratory, a medical clinic, a rehabilitation facility, a dialysis unit, an outpatient center, an assisted care living facility, an emergency room and a nursing home.

24. A method according to claim 18 wherein the patient information collection center is associated with processing health insurance claims.

25. A method according to claim 18 wherein the signal transmitted from the first controller to the second controller includes information relating to a claim for reimbursement relating to medical services being provided to the patient at the medical facility.

26. A method according to claim 25 further comprising transmitting a signal from the second controller transmits to the first controller including an indication of whether or not the claim is a valid claim based on the indication of whether the patient is within the predetermined vicinity of the medical facility.

27. A method according to claim 18 wherein the predetermined information that the patient is prompted to enter is a personal identification number.

28. A method according to claim 18 wherein the predetermined information that the patient is prompted to enter is pressing a number on the telephone in response to a question presented to the patient.

30. A method according to claim 18 further comprising activating a backup locating system to perform a predetermined action based on a predetermined backup event.

31. A method according to claim 30 wherein the predetermined backup event that activates the backup locating system is an indication received from the second controller that the patient is not within the predetermined vicinity of the medical facility.

32. A method according to claim 30 wherein the predetermined action is at least one of calling the patient'"'"'s mobile telephone and speaking with the patient to determine the location of the patient, and providing a notification to the medical facility including a request that the patient contact the patient information collection center to verify the patient'"'"'s location.

33. A method according to claim 30 wherein the predetermined action is calling the medical facility and requiring the patient to verify their location using a predetermined patient identifier.

34. A method according to claim 30 wherein the predetermined action is calling the medical facility and speaking with the patient, and requiring the patient to verify their location using a predetermined patient identifier.