Novel Method and Apparatus for Repricing a Reimbursement Claim Against a Contract

• US 20110153371A1
• Filed: 12/22/2010
• Published: 06/23/2011
• Est. Priority Date: 10/14/1999
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Lesswing, Mark, Hoerle, Dale
• Granted Patent: US 8,160,905 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/04 Trading; Exchange, e.g. stocks, commodities, derivatives or currency exchange
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method for repricing a reimbursement claim under at least one contract is provided herein. The method includes converting each contract into a series of contractual terms, where each contractual terms contains qualification codes, calculation codes and priority notes. The method then converts a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes. The method then begins to compare comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract and when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, the method identifies the contractual term as a matching contractual term associated to the claim line. Upon identifying all matching contractual terms, either to the claim line or the entire claim, the method will determine any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions. The method then calculates the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms. The method may then determine and make any adjustments depending upon any discount terms for the entire reimbursement amount.

Claims

1-11. -11. (canceled)

12. A method of repricing at lease one reimbursement claims, for medical services, under at least one contract comprising:

inputting into a platform, each contract, of the at least one contract, each contract containing a contract identifier code and a series of contractual terms, each contractual term being defined by qualification codes, calculation codes and at least one priority note;

inputting into a platform, each claim, of the at least one claim, each claim containing a second identifier code and a series of claim lines, wherein each claim line being defined by a claim code, a unit number and a corresponding charge;

requesting a platform to reprice a claim, of the at least one claim, by determining a reimbursement amount for said claim; and

requesting a platform to display the reimbursement amount for said repriced claim.

13. The method of claim 12 wherein the step of determining a reimbursement amount includes:

comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract;

when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, identifying said contractual term as a matching contractual term associated to said claim line, and creating a list of all matching contractual terms;

determining any priority conditions associated to the matching contractual terms, and eliminating any matching contractual terms, from said list of matching terms that are excluded by said priority conditions; and

determining a reimbursement charge for each claim line associated to a non-eliminated matching term, and adding the reimbursement charges for said claim lines, wherein the reimbursement amount for the claim is the addition of said reimbursement charges.

14. The method of claim 13 wherein the priority conditions further includes:

categorizing the contractual terms, of each contract, into a set of sequentially listed pre-defined sections, wherein the pre-defined sections have a hierarchy that lists a pre-defined section, having priority over another pre-defined section, before said other pre-defined section.

15. The method of claim 14 wherein the priority conditions further includes:

arranging the contractual terms, categorized in each pre-defined section, in a reverse hierarchy, wherein a contractual term having priority over another contractual term is listed subsequent to said other contractual term.

16. The method of claim 14 wherein the step of comparing each claim code against each qualification code includes:

when the claim further contains a claim priority condition, comparing each claim code only against qualification codes, of contractual terms listed in pre-defined sections that satisfy the claim priority condition.

17. The method of claim 16 wherein the priority conditions include a claim priority condition which eliminates any matching contractual terms that is listed in a pre-defined section that is excluded by the claim priority condition.

18. The method of claim 17 wherein when one of the priority notes associated to a matching contractual term indicates that said matching contractual term reprices the entire claim, eliminating all other matching contractual terms.

19. The method of claim 18 wherein the reverse hierarchy is determined by the priority notes associated to each contractual term, categorized in a pre-defined section.

20. The method of claim 13 wherein the step of repricing further includes:

comparing the claim identifier code against the contract identifier code, of each contract, wherein when the claim identifier code is substantially equal to a contract identifier code, of a contract, identifying said contract as a governing contract; and

determining a reimbursement amount of the claim only against the governing contract.

21. The method of claim 20 wherein the step determining a reimbursement amount for the claim against the governing contract includes:

when at least two contracts are identified as governing contracts, repricing said claim against each governing contract creating a list of governing reimbursement amounts, wherein the reimbursement amount of said claim is the lowest governing reimbursement amount.

22. The method of claim 21 further including:

storing the reimbursement amount of a claim and storing said claim as a repriced claim.

23. The method of claim 22 wherein prior to determining the reimbursement amount for a claim the method including:

comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;

when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, creating a bundled claim having the combined claim lines of the claim lines of said claim with the claim lines of said repriced claim;

determining the reimbursement amount of the bundled claim, instead of determining the reimbursement amount of said claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.

24-59. -59. (canceled)