Automated health benefit processing system

• US 5,225,976 A
• Filed: 03/12/1991
• Issued: 07/06/1993
• Est. Priority Date: 03/12/1991
• Status: Expired due to Term

• Current Assignee: Research Enterprises Corporation
• Original Assignee: Research Enterprises Corporation
• Inventors: Tawil, Jack J.
• Primary Examiner(s): Envall, Roy
• Assistant Examiner(s): BAI, ARI
• Application Number:
  US07/668,035
• Time in Patent Office: 847 Days
• Field of Search: 364/401, 364/406
• US Class Current: 705/2
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• 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: G16H 70/20 relating to practices or guidelines

Abstract

An automated health benefit processing system. The system includes a database and three processors. The database includes, for each geographic area and for each medical procedures for which a benefit is payable, the benefit payable to an insured if the procedure is prescribed and performed, a list of providers available to perform the designated procedure, and each provider'"'"'s charge for performing the designated procedure. The first processor generates a treatment plan concerning the insured that specifies the identity of the insured and the medical procedures to be performed on the insured. The first processor also accesses the database to retrieve the information stored in the database under the medical procedures to be performed and to append this information to the treatment plan. The second processor generates a treatment record specifying the medical procedures actually performed by a provider and the provider'"'"'s actual charge therefor. The third processor processes the information in the treatment plan and treatment records to determine amounts payable to the insured and the provider.

Claims

1. An automated system for processing health benefit claims by an insured, comprising:

a database that, for each of a plurality of procedures, specifies a benefit payable in the event the procedure is prescribed and performed, a list of medical treatment providers available for performing the procedure and each provider'"'"'s charge for performing the procedure;

first processing means for generating a treatment plan that specifies the identity of the insured and one or more procedures to be performed on the insured and for accessing the database to append to the treatment plan the benefit payable, the list of medical treatment providers and each provider'"'"'s charge, for each procedure to be performed;

second processing means for generating a treatment record that specifies, from/the procedures to be performed pursuant to the treatment plan, one or more procedures actually performed on the insured and the actual charge for performing each of the procedures; and

third processing means for processing the treatment plan and the treatment record to determine an amount payable to the insured equalling the amount by which the benefit payable for the procedures actually performed less the actual charges for performing the procedures exceeds zero.

2. The system as claimed in claim 1, wherein the second processing means specifies the identity of the medical treatment provider actually performing the procedures in the treatment record and the third processing means also determines an amount payable to the medical treatment provider equalling the lesser of the actual charges and the benefit payable for the procedures actually performed.

3. The system as claimed in claim 2, wherein the third processing means, prior to determining amounts payable to the insured and to the medical treatment provider, performs security checks by comparing the treatment plan to the treatment record and terminates processing without payment to the insured or to the medical treatment provider if the comparison yields a mismatch.

4. The system as claimed in claim 3, wherein the procedures actually performed, as specified by the treatment record are checked against the procedures to be performed, as specified by the treatment plan, to ensure that the proper procedures were actually performed.

5. The system as claimed in claim 4, wherein identifying information is included in the treatment plan by the first processing means and in the treatment second by the record processing means and the third processing means compares the identifying information.

6. The system as claimed in claim 1, wherein the medical treatment provider'"'"'s charge in the database is updated by the third processing means based of the medical treatment provider'"'"'s latest actual charges for performing the procedure.

7. The system as in claim 1, wherein the list of medical treatment providers available for performing the procedure designated in the database is further subdivided by geographic areas.

8. The system as claimed in claim 1, wherein background information concerning each medical treatment provider is included in the database.

9. The system as claimed in claim 8, wherein the background information includes experience for each procedure, medical specialties, board certifications, years in practice, medical degrees, class rank, residency location, malpractice suits lost and settled, hospital affiliations, university affiliations and any credit cards by which payment can be made.

10. The system as claimed in claim 1, wherein the treatment plan includes any pharmaceutical prescriptions.

11. The system as claimed in claim 10, wherein the database includes background information concerning the pharmaceutical prescription which the first processing means includes in the treatment plan.

12. The system as claimed in claim 1, wherein the information in the database is organized under individual procedures.

13. The system as claimed in claim 1, wherein the information in the database is organized under a group of procedures to be performed according to an episode of illness.

14. The system as claimed in claim 1, wherein each medical treatment provider sought by the insured has access to the second processing means for generating a treatment record and the third processing means compares each treatment record to the treatment plan to determine amounts payable.

15. The system as claimed in claim 1, wherein physicians generate treatment plans for insureds on the first processing means, medical treatment providers generate treatment records for insureds on the second processing means and the third processing means compares each treatment plan to the appropriate treatment records to determine settlement amounts payable.

16. The system as claimed in claim 15, wherein the database, the first processing means, the second processing means and the third processing means are provided in a central processor.

17. The system as claimed in claim 15, wherein the database and the first processing means is located in each physicians'"'"' office that generates treatment plans and the second processing means is located in each medical treatment providers'"'"' office that generates treatment records.