Computerized healthcare accounts receivable purchasing collections securitization and management system

• US 5,550,734 A
• Filed: 12/23/1993
• Issued: 08/27/1996
• Est. Priority Date: 12/23/1993
• Status: Expired due to Term

• Current Assignee: Prudential Securities Credit Corp. LLC (Prudential Financial Incorporated)
• Original Assignee: Pharmacy Fund, Inc.
• Inventors: Tarter, Fred B., Peck, Jan, Greene, Jeffrey M., De Fazio, Thomas J., Hall, Del, Tarter, Scott A., Wylie, L. Stephen, Magnotte, Mark M.
• Primary Examiner(s): McElheny, Jr., Donald E.
• Assistant Examiner(s): Tkacs, Stephen R.
• Application Number:
  US08/175,338
• Time in Patent Office: 978 Days
• Field of Search: 364/401, 364/406, 364/408, 235/375, 235/380
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/4016 involving fraud or risk level assessment in transaction processing
• CPC Class Codes: G06Q 20/403 Solvency checks
• CPC Class Codes: G06Q 30/06 Buying, selling or leasing transactions
• 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

Abstract

The present invention is a computerized method and system for financing health care service providers, especially pharmacies, by evaluating and purchasing their accounts receivables, scoring the creditworthiness of payors and obligors such as insurance companies, self-insured employers, health maintenance organizations, preferred provider organizations, government agencies, and other entities sponsoring groups and individuals receiving health care benefits, collecting on receivables, securitizing receivables, managing funds, and processing and reconciling claims and payments.

Claims

1. A computerized method for financing a health care service provider, comprising:

(a) receiving an electronically transmitted insurance claim from the service provider;

(b) identifying a payor and an obligor associated with the insurance claim;

(c) accessing a profile database record for the payor and obligor;

(d) retrieving a creditworthiness status of the payor and obligor from the profile database record;

(e) determining whether to purchase the insurance claim from the service provider based on the creditworthiness status; and

(f) if the determination is to purchase the insurance claim, making a payment to the service provider for purchase of the insurance claim.

2. A method according to claim 1 wherein the determination is not to purchase the insurance claim from the service provider, further comprising generating a notice to the service provider relating the determination not to purchase the insurance claim and electronically transmitting the notice.

3. A method according to claim 1 wherein the determination is to purchase the insurance claim from the service provider, and wherein the payment to the service provider is made at a discount, further comprising:

(a) generating and sending a notice to the payor and obligor associated with the insurance claim indicating that the insurance claim has been purchased;

(b) determining an amount owed by the payor and obligor;

(c) receiving payment on the insurance claim from the payor; and

(d) reconciling the amount of the payment received from the payor with the amount of payment owed by the payor.

4. A method according to claim 3 wherein reconciling the amount of the payment received from the payor with the amount owed by the payor comprises:

(a) receiving a statement from the payor regarding payment amounts for insurance claims which have been approved for payment;

(b) matching the amount of one or more payments received from the payor with payment amounts indicated on the statement to determine whether discrepancies exist between these amounts;

(c) determining whether each discrepancy is due to an adjustment to the statement, and, if it is, determining whether the service provider or payor is responsible for the adjustment; and

(d) disposing of the adjustment accordingly.

5. A method according to claim 3 further comprising:

(a) accessing a database of creditworthiness scores to identify a creditworthiness score for each payor and obligor associated with a set of insurance claims purchased from service providers;

(b) determining which insurance claims from the set to include in a pool of investment grade receivables based on the creditworthiness scores; and

(c) using the pool to collateralize one or more funding instruments.

6. A method according to claim 5 wherein the steps of determining which insurance claims to include in a pool of investment grade receivables and using the pool to collateralize one or more funding instruments are implemented utilizing an integrated securitization software package.

7. A method according to claim 6 wherein the integrated securitization software package is the Financial Administration and Structuring Technology.

8. A method according to claim 1 wherein the health care service provider is a pharmaceutical service provider.

9. A method according to claim 1 wherein the payment to the service provider is made via an automated clearing house (ACH) transfer to the service provider'"'"'s account.

10. A method according to claim 1 wherein the payment to the service provider is made via a wire transfer to the service provider'"'"'s account.

11. A method according to claim 1 further comprising:

(a) identifying a plan associated with the insurance claim;

(b) accessing a profile database record for the plan; and

(c) retrieving a creditworthiness status of the plan from the profile database record.

12. A method according to claim 1 wherein identifying a payor and an obligor associated with the insurance claim comprises accessing bank identification number (BIN) and group number data stored in a BIN field and a group number field of the electronically transmitted insurance claim and determining the identity of the payor and obligor based on the BIN and group number data.

13. A method according to claim 1 wherein the creditworthiness status of the payor and obligor is established in accordance with the following:

(a) retrievably storing ratings for the payor and obligor obtained from one or more rating agencies;

(b) assigning the ratings into numerical rating categories and retrievably storing the rating categories;

(c) assigning a weighting factor for each rating agency based on the anticipated importance of the rating agency to a relevant investor market, and retrievably storing the weighting factors;

(d) determining a creditworthiness score for each payor and obligor using the rating categories and weighting factors according to the following formula;

##EQU2## where;

q is a given payor and obligor;

CS(q) is the creditworthiness score for the payor and obligor;

w_i are the weighting factors assigned to each rating agency;

R(q)_i are the rating categories to which the ratings for the given payor and obligor are assigned for each of the rating agencies used; and

n is the number of rating agencies used;

(e) determining the creditworthiness status of the payor and obligor from the creditworthiness scores; and

(f) retrievably storing the creditworthiness status in a profile database record.

14. A method according to claim 13 wherein determining the creditworthiness status of the payors and obligors from the creditworthiness scores further comprises:

(a) obtaining a range of possible creditworthiness scores by determining a highest and a lowest possible creditworthiness score;

(b) dividing the range into a desired number of subranges;

(c) determining a highest and a lowest possible creditworthiness score for each subrange; and

(d) determining to which subrange the creditworthiness score for each payor and obligor belongs by comparing the creditworthiness score for each payor and obligor to the highest and lowest possible creditworthiness scores for the subrange.

15. A method according to claim 13 wherein at least one of the ratings used is a performance indicator for a given payor and obligor obtained according to the following:

(a) determining an average amount due associated with the payor and obligor over an average cycle;

(b) retrievably storing the following data;

(i) the average amount due;

(i) an amount of money due associated with the payor and obligor during a given payment cycle;

(ii) a number of days such amount of money due is overdue for the given payment cycle;

(iii) a total of any secured and guaranteed funds for the payor and obligor; and

(c) determining the performance indicator using the following formula;

space="preserve" listing-type="equation">PI=((AD*ND)-SF)/FD,

where;

PI is the performance indicator;

AD is the amount of money due during a given payment cycle;

ND is the number of days said amount of money due is overdue;

SF is the total of any secured or guaranteed funds;

and

FD is the average amount due.

16. A method according to claim 15 wherein the rating agencies, rating categories, and weighting factors are as shown in FIG. 49.

17. A method according to claim 1 wherein determining whether to purchase the insurance claim comprises the steps set forth in FIG. 16.

18. A method according to claim 1 wherein determining whether to purchase the insurance claim comprises the steps set forth in FIG. 21.

19. A method according to claim 1 wherein determining whether to purchase the insurance claim comprises applying the logic set forth in the table in FIG. 28.

20. A method according to claim 1 wherein determining whether to purchase the insurance claim comprises applying the logic set forth in the table in FIG. 29.

21. A method according to claim 1 further comprising utilizing an electronic bulletin board system to provide access to information regarding insurance claim transactions and to provide the means for communication among a plurality of service providers, payors, processors, administrators, and obligors.

22. A method according to claim 1 further comprising a computerized alert process for discovering unusually high processing volume for a given service provider, said process comprising:

(a) determining and retrievably storing;

(i) an average processing volume for the service provider for a selected period of time;

(ii) an average processing volume for the selected period for a set of service providers;

(iii) an average annual processing volume for the set of service providers;

(iv) an index representing the ratio of the average processing volume for the selected period for the set of service providers to the average annual processing volume for the set of service providers;

(v) an expected average processing volume for the service provider representing the product of the index and the average processing volume for that service provider over the selected period; and

(vi) the actual processing volume for the service provider during one period of time which is equivalent to the selected period of time;

(b) comparing the actual processing volume for the service provider to the expected average processing volume for the service provider; and

(c) if the actual processing volume is greater than the expected average processing volume for the service provider by more than a predetermined, adjustable parameter, generating an alert message.

23. A method according to claim 22 wherein the alert process further comprises the steps shown in FIG. 27.

24. A method according to claim 22 wherein the predetermined, adjustable parameter is 50%.

25. A computerized healthcare accounts receivable management system for purchasing accounts receivables from one or more health care service providers, comprising:

(a) means for receiving electronically transmitted insurance claims from one or more service providers;

(b) means for receiving electronically transmitted adjudication response messages from one or more processors approving the insurance claim;

(c) means for matching the insurance claims with the adjudication response messages;

(d) means for identifying a plan, a payor and an obligor associated with each insurance claim;

(e) means for accessing one or more profile database records for the plan, payor and obligor;

(f) means for retrieving creditworthiness statuses of the plan, payor and obligor from the profile database record or records;

(g) means for determining whether to purchase each insurance claim from the service provider based on the creditworthiness statuses; and

(h) means for making payments to the service providers for purchase of the insurance claims.

26. A system according to claim 25 wherein the payments to the service providers are made at a discount, further comprising:

(a) means for generating and sending notices to payors and obligors indicating the insurance claims of a set of service providers are to be purchased;

(b) determining amounts owed by each payor and obligor associated with an insurance claim;

(c) receiving payments on the insurance claims from the payors; and

(d) reconciling the amounts of the payments received from the payors with the amounts of payments owed by the payors.

27. A method according to claim 26 wherein reconciling the amounts of the payments received from the payors with the amounts owed by the payors comprises:

(a) receiving statements from the payors regarding payment amounts for insurance claims which have been approved for payment;

(b) matching the amounts of one or more payments received from the payors with payment amounts indicated on the statements to determine whether discrepancies exist between these amounts;

(c) determining whether each discrepancy is due to an adjustment to each statement, and, if it is, determining whether the service providers or payors are responsible for the adjustment; and

(d) disposing of the adjustments accordingly.

28. A computerized method for purchasing accounts receivables from a health care service provider, comprising:

(a) receiving an electronically transmitted insurance claim from the service provider;

(b) receiving an electronically transmitted adjudication response message from a processor approving the insurance claim;

(c) identifying a plan, a payor and an obligor associated with the insurance claim;

(d) accessing a negative file;

(e) searching the negative file to find the plan, payor, and obligor;

(f) determining whether to purchase the insurance claim from the service provider based on the search and in accordance with the logic set forth in FIG. 29; and

(g) if the determination is to purchase the insurance claim, making a payment to the service provider for purchase of the insurance claim.

29. A computerized system for determining whether to purchase an insurance claim from a service provider comprising:

(a) means for identifying a payor and obligor associated with the insurance claim;

(b) means for determining an average amount due associated with the payor and obligor over an average cycle;

(c) means for retrievably storing the following data;

(i) ratings for the payor and obligor obtained from one or more rating agencies;

(ii) weighting factors for each rating agency based on its anticipated importance to an investor market;

(iii) the average amount due;

(iv) an amount of money due associated with the payor and obligor during a given payment cycle;

(v) a number of days such amount of money due is overdue for the given payment cycle;

(vi) a total of any secured and guaranteed funds for the payor and obligor;

(d) means for determining a performance indicator according to the following algorithm;

space="preserve" listing-type="equation">PI=((AD*ND)-SF)/FD,

where;

PI is the performance indicator;

AD is the amount of money due during a given payment cycle;

ND is the number of days said amount of money due overdue;

SF is the total of any secured or guaranteed funds;

and

FD is the average amount due;

(e) means for assigning the ratings and the performance indicator into numerical rating categories;

(f) means for determining the creditworthiness score according to the following formula;

##EQU3## where;

q is a given payor and obligor;

CS(q) is the creditworthiness score for the payor and obligor;

w_i are the weighting factors assigned to each of rating agencies;

R(q)_i are the rating categories to which the ratings for the given payor and obligor are assigned for each of the rating agencies used; and

n is the number of rating agencies used;

(g) means for electronically communicating the creditworthiness scores;

(h) means for identifying the payors and obligors associated with the insurance claim; and

(i) means for determining whether to purchase an insurance claim based on the creditworthiness score of one or more of the identified payors and obligors.

30. A system according to claim 29 wherein the rating agencies, rating categories, and weighting factors are as shown in FIG. 49.

31. A computerized healthcare accounts receivable purchasing, collections, securitization and management method for evaluating and purchasing the accounts receivables of subscribing pharmaceutical service providers, scoring the creditworthiness of payors and obligors, collecting on and securitizing accounts receivables, and reconciling claims and payments, comprising:

(a) establishing and retrievably storing a provider profile database comprising a plurality of records which contain information regarding subscribing pharmaceutical service providers;

(b) establishing and retrievably storing one or more plan, payor, and obligor profile databases comprising a plurality of records which contain information regarding plans, payors, and obligors;

(c) establishing a creditworthiness status for each plan, payor and obligor contained in the plan, payor and obligor profile database or databases and retrievably storing the creditworthiness status in the profile database records for the plan, payor, and obligor;

(d) receiving electronically transmitted insurance claims over an on-line pharmaceutical claims adjudication network which utilizes an a National Council for format;

(e) receiving NCPDP standard format adjudication responses approving payment for the insurance claims, which adjudication responses were electronically transmitted by one or more processors over the on-line pharmaceutical claims adjudication network;

(f) matching the insurance claims with the responses;

(g) identifying a plan, a payor, and an obligor associated with each insurance claim by accessing BIN and group number data stored in a BIN field and a group number field of each electronically transmitted insurance claim and determining the identity of the plan, payor and obligor based on the BIN and group number data;

(h) accessing one or more records for the plan, payor and obligor associated with each insurance claim from the plan, payor and obligor profile database or databases;

(i) retrieving the creditworthiness status of the plan, payor and obligor from the profile database record or records;

(j) determining which insurance claims to purchase from the pharmaceutical service providers based on the creditworthiness statuses in accordance with the procedure shown in FIG. 21 and applying the logic set forth in the table shown in FIG. 29;

(k) making payments at a discount to the service providers whose insurance claim or claims are to be purchased, which payment is made via an ACH transfer;

(l) generating and transmitting notices to the payors and obligors contained in the payor and obligor profile database or databases that insurance claims of the pharmaceutical service providers contained in the provider profile database are being purchased;

(m) receiving payments on the insurance claims from the payors;

(n) reconciling the amounts of the payments received from the payors with the amounts of payment owed by the payors, comprising;

(i) receiving statements from the payors regarding payment amounts for insurance claims which have been approved for payment;

(ii) matching the amount of one or more payments received from the payor with payment amounts indicated on the statements to determine whether discrepancies exist between these amounts;

(iii) determining whether each discrepancy is due to adjustments to the statements, and, if it is, determining whether the service provider or payor is responsible for the adjustment; and

(iv) disposing of the adjustments in accordance with the logic set forth in the tables in FIGS. 31-32A;

(o) utilizing an integrated securitization software package to securitize the accounts receivables of the service providers, comprising;

(i) accessing a database of creditworthiness scores to identify a creditworthiness score for each payor and obligor associated with the accounts receivables purchased from service providers;

(ii) determining which insurance claims to include in a pool of investment grade receivables based on the creditworthiness scores; and

(iii) using the pool to collateralize one or more funding instruments;

(p) determining whether processing volume for each service provider is unusually high for a selected period of time, and generating an alert message, comprising;

(i) determining and retrievably storing;

an average processing volume for each service provider for a selected period of time, an average processing volume for the selected period for the service providers, an average annual processing volume for the service providers, an index representing the ratio of the average processing volume for the selected period for the service providers to the average annual processing volume for the service providers, an expected average processing volume for each service provider representing the product of the index and the average processing volume for that service provider over the selected period, and the actual processing volume for each service provider during one period of time which is equivalent to the selected period of time;

(ii) comparing the actual processing volume for each service provider to the expected average processing volume for each service provider; and

(iii) if the actual processing volume is greater than the expected average processing volume for each service provider by more than a predetermined, adjustable parameter, generating an alert message;

(q) receiving and responding to inquiries transmitted by service providers over the on-line pharmaceutical claims adjudication network and containing requests for information stored in database records, comprising;

(i) identifying the electronically transmitted insurance claim message as an inquiry;

(ii) reading from the inquiry and retrievably storing a code indicating the date of the information requested and a code indicating the type of information requested, wherein the types of information comprise deposit summary information, deposit/adjustment detail information, non-purchased detail information, and bulletin information;

(iii) determining the date of the information requested and the type of information requested by converting the codes according to predefined parameters;

(iv) identifying one or more database records containing the type of information requested for the date of the information requested;

(v) accessing the database record or records to obtain and retrievably store the requested information;

(vi) opening a response message in the form of an NCPDP standard rejected claim response message;

(vii) transferring the requested information into one or more message text fields of the response message; and

(viii) electronically transmitting the response message over the on-line pharmaceutical adjudication network to the service provider; and

(r) retrieving information about pharmaceutical service provider financial accounts stored in one or more database files, comprising;

(i) displaying two or more display screens each containing one or more fields in which a user can input information, wherein the display screens and fields are as shown in FIGS. 17A through 17P;

(ii) capturing information inputted into the fields;

(iii) switching between display screens at the press by the user of a hot key;

(iv) converting the information inputted by the user into a set of requested information;

(v) accessing and retrieving the requested information from the database files; and

(vi) displaying to the user the information accessed from the database files.

32. A method according to claim 31 wherein establishing a creditworthiness status for each payor and obligor comprises:

(a) determining an average amount due associated with the payor and obligor over an average cycle;

(b) retrievably storing the following data;

(i) ratings for the payor and obligor obtained from one or more rating agencies;

(ii) weighting factors for each rating agency based on its anticipated importance to an investor market;

(iii) the average amount due;

(iv) an amount of money due associated with the payor and obligor during a given payment cycle;

(v) a number of days such amount of money due is overdue for the given payment cycle;

(vi) a total of any secured and guaranteed funds for the payor and obligor;

(c) determining a performance indicator according to the following algorithm;

space="preserve" listing-type="equation">PI=((AD*ND)-SF)/FD,

where;

PI is the performance indicator;

AD is the amount of money due during a given payment cycle;

ND is the number of days said amount of money due is overdue;

SF is the total of any secured or guaranteed funds;

and

FD is the average amount due;

(d) assigning the ratings and the performance indicator into numerical rating categories;

(e) determining the creditworthiness score according to the following formula;

##EQU4## where;

q is a given payor and obligor;

CS(q) is the creditworthiness score for the payor and obligor;

w_i are the weighting factors assigned to each of rating agencies;

R(q)_i are the rating categories to which the ratings for the given payor and obligor are assigned for each of the rating agencies used; and

n is the number of rating agencies used;

(f) obtaining a range of possible creditworthiness scores by determining a highest and a lowest possible creditworthiness score;

(g) dividing the range into a desired number of subranges;

(h) determining a highest and a lowest possible creditworthiness score for each subrange;

(i) determining to which subrange the creditworthiness score for each payor and obligor belongs by comparing the creditworthiness score for each payor and obligor to the highest and lowest possible creditworthiness scores for the subrange; and

wherein the rating agencies, rating categories, and weighting factors are as shown in FIG. 49.