SYSTEMATIC PAYMENT AUDITING

• US 20110112851A1
• Filed: 11/12/2009
• Published: 05/12/2011
• Est. Priority Date: 11/12/2009
• Status: Abandoned Application

• Current Assignee: Source Medical Solutions, Inc. (SIS Holding Corp.)
• Original Assignee: Nobelus, Inc.
• Inventors: Poley, Craig
• Application Number:
  US12/617,533
• Publication Number:
  US 20110112851A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 40/12 Accounting

Abstract

A systematic audit of payment amounts for collections received for billed service is performed to identify payment discrepancies. Prices are assigned to service codes by government payers and private insurance companies with numerous variations. Each type of price model and variant is stored in a data repository. The price model may be categorized and applied per facility and per payer. Payment amounts are analyzed for price and billing code accuracy to determine whether the received payment accurately reflects the pricing model.

Claims

1. A computer system for medical payment analysis, the computer system comprising:

a machine capable of executing instructions embodied as software; and

a plurality of software portions stored on a first memory coupled to the machine, wherein

one of said software portions is configured to store in a second memory a plurality of payment amounts received from a facility wherein each payment amount is associated with a claim and wherein each claim includes at least one billing code,

one of said software portions is configured to validate a plurality of pricing models stored in the first memory,

one of said software portions is configured to retrieve from the first memory the plurality of pricing models and to retrieve from the second memory the plurality of payment amounts,

one of said software portions is configured to associate each of the plurality of payment amounts with one of the plurality of pricing models based on the claim submitted by the facility and the at least one billing code,

one of said software portions is configured to associate a target amount for the at least one billing code based on the associated pricing model, and

one of said software portions is configured to compare the associated target amount to each payment amount to identify a payment discrepancy and wherein responsive to identifying the payment discrepancy, identifying the payment amount as a failed claim to an end user.

2. The computer system of claim 1 wherein each of the plurality of pricing models is associated the at least one billing code.

3. The computer system of claim 2 wherein the at least one billing code and its associated target amount is uniquely associated to a payer.

4. The computer system of claim 3 wherein the payer is an insurance company.

5. The computer system of claim 3 wherein the payer is a government agency.

6. The computer system of claim 1 wherein the pricing model is associated with a payer.

7. The computer system of claim 1 wherein the target amount is associated with the at least one billing code.

8. The computer system of claim 7 wherein, responsive to the target amount failing to be associated with the billing code, assigning an average target amount based on the associated pricing model.

9. The computer system of claim 1 wherein responsive to the payment amount matching the target amount, identifying the payment amount as a passing claim to the end user via a user interface.

10. The computer system of claim 1 further comprising a software portion configured to identify a reason for the payment discrepancies.

11. The computer system of claim 10 wherein the reason for the payment discrepancy is stored in a third memory.

12. The computer system of claim 10 further comprising a software portion configured to identify the reason for the payment discrepancy as based on billing code sequencing.

13. The computer system of claim 10 further comprising a software portion configured to identify the reason for the payment discrepancy as based on mutually exclusive billing code coding policies of the pricing model.

14. The computer system of claim 10 further comprising a software portion configured to identify the reason for the payment discrepancy as based on payers limiting a number of maximum payable billing codes submitted on a claim.

15. The computer system of claim 1 further comprising a software portion configured to modify claim submittal procedures based on the payment discrepancy.

16. The computer system of claim 1 further comprising a software portion configured to update in the first memory the associated pricing model based on the payment discrepancy stored in the third memory.

17. A computer-readable storage medium tangibly embodying a program of instructions executable by a machine wherein said program of instructions comprises a plurality of program codes for identifying discrepancies in payment amounts for billed services, said program of instructions comprising:

program code for recording in a first memory a plurality of received payments wherein each received payment is associated with at least one payment claim and wherein the at last one payment claim is associated with at least one payment billing code;

program code for accessing from a second memory a plurality of pricing models wherein each pricing model is associated with a plurality of claim billing codes and wherein each claim billing code is associated with a target payment;

program code for associating each of the plurality of received payments with one of the plurality of pricing models based on matching at least one claim billing code associated with one of the pricing models with at least one payment billing code associated with the at least one payment claim;

program code for determining the target payment based on the corresponding matched at least one claim billing code;

program code for comparing the received payment with the target payment associated with the matched at least one claim billing code wherein responsive to the received payment failing to match the target payment identifying a payment discrepancy; and

program code for determining whether the payment discrepancy is justified or unjustified wherein responsive to determining that the payment discrepancy is unjustified, adding the payment discrepancy to a list of payment discrepancies, and wherein responsive to identifying the payment discrepancy is justified, updating the pricing model in the second memory including the claim billing codes and the target payments.

18. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein program code for determining is further configured to determine whether the payment discrepancy is caused by a billing code segueing discrepancy.

19. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein determining whether the payment discrepancy is caused by a bundling policy violation.

20. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein determining whether the payment discrepancy is caused by a charge amount violation.

21. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein determining whether the payment discrepancy is caused by a billing code mutually exclusive policy violation.

22. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein determining whether the payment discrepancy is caused by a payer-instituted limit on a maximum number of payable billing codes on a claim for rendered services.

23. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein correcting the payment discrepancy includes submitting a revised claim to the payer.

24. A computer-readable storage medium tangibly embodying the program of instructions of claim 17 wherein correcting the payment discrepancy includes initiating an appeal process.

25. A computer implemented method for identifying discrepancies in payment amounts received for billed services, the method comprising:

receiving from a facility a plurality of payment amounts for services rendered wherein each payment amount is associated with a claim and at least one payment billing code;

storing the plurality of payment amounts in a first memory;

retrieving from the facility and storing in a second memory a plurality of pricing models wherein each pricing model includes a plurality of claim billing codes and wherein each claim billing code is associated with a target payment;

associating by a microprocessor coupled to the first and second memory each of the plurality of payment amounts with one of the plurality of pricing models based on the claim and the at least one payment billing code associated with the payment amount as compared to the claim billing codes of the pricing models;

assigning in the first memory a target amount for each payment amount based on the associated pricing model;

comparing in the first memory the associated target amount with each payment amount and identifying at least one payment discrepancy when the associated target amount fails to match the payment amount;

determining whether the at least one payment discrepancy is justified; and

responsive to determining that the payment discrepancy is not justified, identifying a course of action to correct the payment discrepancy.

26. The method of claim 25 further comprising creating a list of claims having payment discrepancies.

27. The method of claim 25 wherein responsive to determining that the payment discrepancy is justified updating the associated pricing model based on the payment billing code and payment amount.

28. The method of claim 25 wherein the revised claim and the payment discrepancy are stored in a third memory.