Medical insurance verification and processing system

• US 4,491,725 A
• Filed: 09/29/1982
• Issued: 01/01/1985
• Est. Priority Date: 09/29/1982
• Status: Expired due to Term

• Current Assignee: Lawrence E. Pritchard
• Original Assignee: Lawrence E. Pritchard
• Inventors: Pritchard, Lawrence E.
• Primary Examiner(s): NOT, DEFINED
• Assistant Examiner(s): Lev, Robert G.
• Application Number:
  US06/426,982
• Time in Patent Office: 825 Days
• Field of Search: 235/377, 235/375, 235/376, 235/383, 235/385, 235/451, 235/432, 235/449, 235/471, 235/380, 194/DIG. 9, 364/413, 364/415, 364/406, 364/401, 364/403, 364/464, 364/436
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/10 specially adapted for electronic funds transfer [EFT] systems; specially adapted for home banking systems
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G07F 17/0014 for vending, access and use of specific services not covered anywhere else in G07F17/00 meter-controlled dispensing of liquid, gas or electricity G07F15/00
• CPC Class Codes: G16H 10/65 stored on portable record carriers, e.g. on smartcards, RFID tags or CD

Abstract

A medical claim verification and processing system reads a medical information card (MEDICARD) to determine a patient'"'"'s background medical and insurance information. The validity of the card is rapidly determined by accessing a central brokerage computer. A local service provider enters into a local terminal the medical and MEDICARD information services provided or to be provided to the patient by using a patient service code and transmits this information to a central brokerage computer. The central brokerage computer converts the patient service code input by the service provider or MEDICARD into a particular service code for the patient'"'"'s insurance carrier. This service code is then utilized to determine the insurance claim payment for that particular patient service. The claim payment amount for the medical service is then transmitted back to the local entry terminal for use by the service provider and patient. The service provider and patient can then determine the amount of payment which will be made for the particular insurance claim. The provider can then prepare an electronic claim form and, together with the patient'"'"'s and/or the provider'"'"'s determination whether or not the assignment provision of the insurance claim will be invoked, the electronic claim form is then transmitted to a central brokerage computer which in turn transmits the claim form to the appropriate insurance carrier. The patient'"'"'s insurance carrier processes the claim form, and, based upon the assignment decision, transfers the payment check to the patient or makes an electronic funds transfer to an account for the service provider, the patient or a central brokerage computer.

Claims

1. A method for rapidly determining an insurance claim payment for a specified patient service, comprising the steps of:

storing in a system memory a file for each of the plurality of insurance carriers, each file having a set of service codes with a claim payment for each service code,

storing in a system memory a code conversion table for each of said insurance carriers for converting patient treatment codes into service codes for the corresponding insurance carrier wherein said patient treatment codes correspond respectively to patient services,

transmitting through a system input device codes for the name of a selected patient and a selected one of said treatment codes corresponding to said specified patient service,

determining the selected patient'"'"'s insurance carrier,

machine reading the code conversion table for the selected patient'"'"'s insurance carrier to translate the selected treatment code into the corresponding service code for the patient'"'"'s insurance carrier,

machine reading the file for the patient'"'"'s insurance carrier to determine the claim payment for the service code which is produced by the translation of said patients treatment code, and

displaying via a system output device said determined claim payment for said specified patient service for said selected patient, said input and output devices located at a common site.

2. A method as recited in claim 1 wherein said files and said conversion tables are stored at a site wherein said selected patient receives said specified patient service.

3. A method as recited in claim 1 wherein said files and said conversion tables are stored at a remote site from a local site at which said selected patient receives said specified patient service, the method including the steps of:

transmitting said selected patient'"'"'s name and said selected treatment code from said local site to said remote site and,

transmitting said determined claim payment from said remote site to said local site.

4. A method as recited in claim 1 wherein the step of determining the selected patient'"'"'s insurance carrier comprises reading a card corresponding to said selected patient and having said codes for said selected patient'"'"'s insurance carrier stored thereon.

5. A method as recited in claim 1 wherein the step of determining the selected patient'"'"'s insurance carrier comprises reading a file comprising the names of said patients and the insurance carrier for each said patient.

6. A method as recited in claim 1 wherein the step of transmitting through a system input device the name for a selected patient and a selected one of said treatment codes comprises the steps of:

machine reading a card having stored therein at least a code for the name of the selected patient, and

entering said selected treatment code into said system input by use of a manually operated device.

7. A method for rapidly verifying insurance coverage and determining an insurance claim payment for a specified patient service at a local site, comprising the steps of:

storing in a remote site system memory a plurality of patient files, each patient file including codes for at least the patient'"'"'s name, insurance carrier and type of insurance coverage,

storing in said remote site memory a file for each of a plurality of insurance carriers, each file having a set of service codes with a claim payment schedule for each service code,

storing in said remote site memory a code conversion table for each of said insurance carriers for converting patient treatment codes into service codes for the corresponding insurance carrier wherein said patient treatment codes correspond respectively to patient services,

transmitting through a system input device at said local site the name for a selected patient and a selected one of said patient treatment codes corresponding to said specified patient service,

communicating codes for at least said selected patient name and said selected treatment code from said local site to said remote site,

machine reading at said remote site the patient file corresponding to the selected patient'"'"'s name to determine the selected patient'"'"'s insurance carrier and to determine the validity of the patient'"'"'s insurance coverage,

machine reading the code conversion table for the selected patient'"'"'s insurance carrier to translate said selected treatment code into the corresponding service code for the selected patient'"'"'s insurance carrier,

machine reading the file for the selected patient'"'"'s insurance carrier to determine the claim payment for the service code produced by the translation of said patient treatment code,

communicating said determined claim payment from said remote site to said local site, and

displaying via a system output device at said local site said determined claim payment for the specified patient service for said selected patient.

8. A method as recited in claim 7 wherein the step of transmitting through a system input device at said local site comprises the steps of:

reading a card having codes therein for at least the name of said selected patient, and

entering said selected treatment code into said system input device by use of a manually operated device.

9. A method as recited in claim 8 including the step of reading said card to produce a code identifying the insurance carrier for said selected patient.

10. A method as recited in claim 8 including the steps of:

transmitting an identification code for one of said cards from said local site to said remote site,

determining at said remote site the validity of said card corresponding to said identification code,

transmitting said validity determination from said remote site to said local site, and

displaying said validity determination at said local site.

11. A method as recited in claim 7 including the steps of:

preparing an electronic insurance claim form at said local site for said selected patient,

communicating said insurance claim form from said local site to said remote site,

communicating said insurance claim form from said remote site to the insurance carrier for said selected patient, and

communicating a funds transfer order corresponding to said determined claim payment schedule to effect a funds transfer from said selected patient'"'"'s insurance carrier to a financial account for the provider of said specified patient service.

12. A method as recited in claim 11 including the step of printing at said local site an insurance claim form corresponding to said electronic insurance claim form for said selected patient.

14. A method as recited in claim 12 including the steps of:

preparing an electronic insurance claim form by the provider of said specified patient service, and

communicating said electronic insurance claim form from an office of said provider of said specified patient service to the selected patient'"'"'s insurance carrier.

15. A method as recited in claim 14 wherein the step of communicating said electronic insurance claim form comprises:

telecommunicating said electronic insurance claim form from said provider'"'"'s office to a central brokerage computer, and

telecommunicating said electronic insurance claim form from said central brokerage computer to said selected patient'"'"'s insurance carrier.

18. A method as recited in claim 12 wherein the step of communicating an electronic insurance claim form comprises:

telecommunicating said electronic insurance claim form from said providers office to a central brokerage computer, and

telecommunicating said electronic insurance claim form from said central brokerage computer to said selected patient'"'"'s insurance carrier.

13. The method for rapidly determining an insurance claim payment for a specified patient service in carrying out payment therefor, comprising the steps of:

storing in a system memory a file for each of a plurality of insurance carriers, each file having a set of service codes with a claim payment for each service code,

storing in a system memory a code conversion table for each of said insurance carriers for converting patient treatment codes into service codes for the corresponding insurance carrier wherein said patient treatment codes correspond respectively to patient services,

determining the insurance carrier for said selected patient,

transmitting through a system input device codes for the name for a selected patient in a selected one of said treatment codes corresponding to said specified patient services,

machine reading the code conversion table for the selected patient'"'"'s insurance carrier to translate the selected treatment code into the corresponding service code for the patient'"'"'s insurance carrier,

machine reading the file for the patient'"'"'s insurance carrier to determine the claim payment for the service code produced by the translation of said selected treatment code,

displaying via a system output device said determined claim payment for said specified patient service for said selected patient, said input and said output devices located at a common site, and

transferring the amount of said determined claim payment from an account for said selected patient'"'"'s insurance carrier to an account for a provider of said specified patient service.

16. A method as recited in claim 13 wherein the step of transferring comprises:

transferring said determined claim payment amount from the account for said selected patient'"'"'s insurance carrier to a central brokerage account, and

transferring said determined claim payment amount from said central brokerage account to said account for said provider of said specified patient service.

17. A method for rapidly determining an insurance claim payment for a specified patient service in carrying out payment therefor, comprising the steps of:

storing in a system memory a file for each of a plurality of insurance carriers, each file having a set of service codes with a claim payment for each service code,

storing in a system memory a code conversion table for each of said insurance carriers for converting patient treatment codes into service codes for the corresponding insurance carrier wherein said patient treatment codes correspond respectively to patient services,

determining the insurance carrier for said selected patient,

transmitting through a system input device codes for the name for a selected patient and a selected one of said treatment codes corresponding to said specified patient services wherein the provider of said specified patient service has a fee for said specified patient service,

machine reading the code conversion table for the selected patient'"'"'s insurance carrier to translate the selected treatment code into the corresponding service code for the patient'"'"'s insurance carrier,

machine reading the file for a patient'"'"'s insurance carrier to determine the claim payment for the service code produced by the translation of said selected treatment code,

displaying via a system output device said determined claim payment for said specified patient service for said selected patient, said input and output devices located at an office for said provider, communicating an electronic insurance claim form from an office of said provider to the selected patient'"'"'s insurance carrier,

transferring said fee amount from a central brokerage account to an account for said provider of said specified patient service,

transferring a difference amount by which said fee amount exceeds said determined claim payment from an account for said selected patient to said central brokerage account, and

transferring said determined claim payment amount from an account for said selected patient'"'"'s insurance carrier to said central brokerage account.

19. A method for determining the validity of insurance coverage and vital medical information for a patient, comprising the steps of:

recording codes on a card for at least the following information items;

(a) patient'"'"'s name,

(b) patient'"'"'s blood type,

(c) patient'"'"'s insurance carrier,

(d) date of patient'"'"'s effective insurance coverage,

entering said card into a stand-alone reader machine having a display screen,

reading said card to determine said information items, and

displaying said information items on said reader machine display screen.

20. A method as recited in claim 19 wherein said card has recorded thereon additional codes for:

(a) the patient'"'"'s medical history,

(b) the patient'"'"'s address,

(c) emergency notification for the patient'"'"'s doctor and relatives,

(d) flight security status for the patient,

(e) organ donor information for the patient, and

(f) the patient'"'"'s social security account number.

21. A method as recited in claim 19 wherein at least a part of said codes are permanently embossed on said card and a further part of said codes are recorded magnetically on said card to permit erasing and updating.