Medical transaction system

• US 5,644,778 A
• Filed: 11/02/1993
• Issued: 07/01/1997
• Est. Priority Date: 11/02/1993
• Status: Expired due to Fees

• Current Assignee: Adminastar Communications Incorporated
• Original Assignee: Athena of North America Incorporated
• Inventors: Schweitzer, Sheila H., Schick, Robert R., Burks, James L.
• Primary Examiner(s): Shah, Alpesh M.
• Application Number:
  US08/147,156
• Time in Patent Office: 1,337 Days
• Field of Search: 395/800, 395/DIG. 1, 395/200.03, 395/200.05, 395/200.15-200.18, 395/840, 395/182.02, 395/185.01, 395/185.1, 395/600, 395/650, 395/700, 364/280, 364/280.4, 364/284.4, 364/406, 364/200, 364/800, 364/401, 364/413.02, 364/413.13, 364/705.06, 370/60, 370/85.1, 370/85.13, 370/94.1, 235/375, 235/379, 235/380, 371/8.2, 371/20.1
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• 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

Abstract

A medical transaction system is disclosed which is capable of permitting a plurality of healthcare providers to communicate with a plurality of payors and financial institutions. The healthcare providers, payors, and financial institutions do not have to communicate in the same data message formats nor in the same communication protocols. Such a system facilitates not only the processing of medical claims submitted by the healthcare providers to the payors, but also permits the transfer of medical data records between healthcare providers. The system supports the processing of medical claims without requiring a centralized database or imposing a uniform claim format on the healthcare providers and payors. The preferred embodiment of the invention further includes a financial transactor that uses remittance information from the payors to generate the electronics funds transfer messages to credit and debit accounts. Additionally, the system supports a medical line of credit at financial institutions that may be used to pay portions of medical claims not covered by payors.

Claims

1. A medical transaction system for communicating data messages between a plurality of computer stations located at healthcare providers and payors, comprising:

a communication receiver for receiving data messages related to patient care activities performed by said healthcare providers, said messages received from said computer stations at said healthcare providers in a plurality of formats and protocols recognized by said communications receiver;

a compiler for compiling patient care information from said date messages received from said computer stations to form a plurality of patient care records having a single common format that is independent of at least one of said plurality of formats and protocols recognized by said communication receiver;

an extractor for extracting ones of said patient care records in accordance with a computer station identification code;

a formatter for formatting said extracted patient care records in a format corresponding to said computer station identification code;

a communications transmitter for transmitting said formatted patient care records to said computer station identified by said identification code in a format and protocol recognized by said identified computer station;

a verifier for verifying data fields within said data messages received from said computer stations and generating an error record indicating when at least one data field within one of said received data messages failed verification; and

a response generator for converting said error record into an error message with a format corresponding to said computer station that sent said failed data message;

wherein said communication transmitter transmits said formatted error message to said computer station.

2. The system of claim 1 wherein said verifier generates a patient care transaction database, said patient care transaction database including all said data fields of said verified data messages and identifying information for said data messages that failed verification.

3. The system of claim 2 further comprising:

an analyzer to generate statistical data from said patient care records in said patient care transaction database.

4. The system of claim 2 further comprising:

a financial transactor for generating electronic funds transfer messages in response to remittance information in said patient care records received from said computer stations located at said payors;

said formatter formats said electronic funds transfer messages in a format corresponding to a computer station identification code for a computer station located at a financial institution; and

said communications transmitter transmits said formatted electronic funds transfer messages to said computer station identified by said computer station identification code in accordance with a protocol corresponding to said computer station identification code.

5. The system of claim 4 wherein said electronic funds transfer messages include a debit message for debiting an account at a financial institution.

6. The system of claim 5 wherein said account is a medical health credit line account.

7. The system of claim 4 wherein said formatter formats said electronic funds transfer messages in format corresponding to a financial institution computer station identification code.

8. The system of claim 1 wherein said formats for said data messages communicated by a group of said computer stations correspond to one of an ANSI 835 and ANSI 837 formats.

9. The system of claim 1 wherein said communication receiver receives data messages indicating a medical claim by a healthcare provider from said computer stations located at said healthcare providers, said data messages having a format and protocol corresponding to a computer station identification code for said healthcare provider submitting a medical claim;

said compiler compiles claim information from said received data messages, and;

said communication transmitter transmits said compiled claim information to said computer stations located at said payors in accordance with a communication protocol and format corresponding to a computer station identification code for said payor to which a medical claim is being submitted.

10. The system of claim 9 wherein said compiler formats said compiled claim information in a patient care record having a single common format that is independent of all of said plurality of formats and protocols recognized by said communication receiver.

11. The system of claim 10 further comprising:

an analyzer to generate statistical data from said patient care records.

12. A medical transaction system for communicating medical data messages comprising:

a communication layer for communicating data messages related to patient care activities performed by healthcare providers with a plurality of computer stations, said data messages being communicated in a plurality of communication protocols and being formatted in a plurality of data message formats recognized by said communication layer; and

a medical transaction processing kernel for compiling patient care information from data messages received from said computer stations at said healthcare providers in different formats and different communications protocols, generating patient care records having a single common format that is independent of at least one of said plurality of formats and protocols recognized by said communication layer, and extracting a portion of said compiled patient care information for transmission to said computer stations, said medical transaction processing kernel comprising

a compiler for compiling patient care information from said data messages received from said computer stations and for formatting said complied information into a patient care record;

an extractor for extracting selected ones of said patient care records corresponding to a computer station identification code;

a formatter for formatting said extracted patient care records in a format corresponding to said computer station identification code;

a verifier for verifying data fields within said patient care records, said verifier generating error records in response to said verifier determining one of said data fields within a patient care record contains data of an incorrect type, said error record including identifying information for identifying said patient care record that failed verification and said computer station that sent said data message used to generate said failed patient care record.

13. The system of claim 12, said communication layer including:

a transaction manager for receiving and transmitting said data messages in said plurality of communication protocols.

14. The system of claim 12, said communications layer further comprising:

a service routine for generating data messages requesting security information from one of said computer stations communicating with said communication layer and terminating communication between said communication layer and said one of said computer stations in response to determining said computer station is unauthorized to communicate with said communication layer.

15. The system of claim 12, said kernel further comprising:

a response generator for converting said error records to error messages having a format corresponding to a computer station identification code for said computer station identified in said error record.

16. The system of claim 15, said kernel further comprising:

a data buffer for receiving from said communications layer said data messages received from said computer stations, said data buffer passing said collected data messages to said compiler at a rate less than the rate said data buffer receives said collected data messages.

17. The system of claim 16, said data buffer further comprising:

transmission file for collecting said collected data messages; and

a disc scanner for periodically searching said transmission file to locate said collected data messages that are unprocessed and passing said unprocessed collected data messages to said compiler.

18. The system of claim 12, said kernel further comprising:

a financial transactor for examining remittance information contained within a patient care record generated by said compiler, said financial transactor for generating electronic funds transfer data messages in response to said remittance information, said financial transactor for formatting said electronic funds transfer data messages in a format corresponding to one of said computer station identification codes.

19. The system of claim 18 wherein at least one of said computer stations is located at one of a credit processor and financial institution, said financial institution and credit processor for managing and processing credit lines for medical services secured to individuals, and

said financial transactor generates credit authorization messages for requesting whether sufficient credit is available to cover a portion of a medical claim not paid by an insurance carrier and generating electronic funds transfer messages in response to said credit processor and financial institution transmitting a data message to said system that credit is available to pay said uncovered portion of said medical claim.

20. The system of claim 12 further comprising:

a transaction database comprised of patient care records and error records written to said transaction database by said verifier.

21. The system of claim 20 further comprising:

a statistical analyzer for analyzing the compiled information within said patient care records so that information about said messages and their content flowing through said medical transaction system may be studied.

22. The system of claim 20 wherein said transaction database includes medical data records, medical claim records, and remittance records.

23. The system of claim 12 wherein a group of computer stations within said plurality of computer stations are located at a plurality of healthcare providers and payors, at least two of said computer stations at said healthcare providers and at least two of said computer stations at said payors communicate with said communications layer in an ANSI 837 format.

24. The system of claim 23 wherein said two of said computer stations at said healthcare providers format said data messages within said ANSI 837 format differently.

25. The system of claim 23 wherein said two of said computer stations at said payors format said data messages within said ANSI 837 format differently.

26. The system of claim 12 wherein a group of computer stations within said plurality of computer stations are located at a plurality of financial institutions and payors, at least two of said computer stations at said payors communicate with said communications layer in an ANSI 835 format.

27. The system of claim 26 wherein said two of said computer stations at said payors format said data messages differently from one another.

28. The system of claim 26 wherein said two of said computer stations at said financial institutions format said data messages differently.

29. A method for communicating medical transactions between a plurality of computer stations, some of said computer stations being located at healthcare providers and some of the said computer stations being located at payors, said method comprising:

communicating data messages related to patient care activities performed by healthcare providers with said plurality of computer stations at said healthcare providers and said payors in a plurality of data message formats and in a plurality of communication protocols; and

processing data messages received from said computer stations at said healthcare providers in different formats and different communications protocols to compile patient care information from said received data messages and format said compiled information to generate patient care records having a single common format that is independent of at least one of said plurality of formats and protocols, said processing further comprising

extracting a portion of said compiled patient care information by extracting ones of said patient care records that correspond to a computer station identification code,

formatting said extracted patient care records in a data message format corresponding to a computer station identification code to generate data messages for transmission to said computer stations,

verifying that data fields within said patient care records contain data of the correct data type,

generating an error record in response to determining that a data field of a patient care record does not contain data of the correct type; and

identifying said patient care record that contained said data field not having the correct type of data.

30. The method of claim 29, said communicating step further comprises:

receiving data messages from said plurality of computer stations in a plurality of data message formats; and

transmitting data messages to said plurality of said computer stations in a plurality of data message formats and communication protocols.

31. The method of claim 30, said receiving step further comprising:

collecting data messages communicated from said plurality of computer stations at a first rate; and

providing said collected data messages to said compiling step at a rate less than said collecting rate.

32. The method of claim 29, said communicating step further comprising:

securing said communication with said computer stations so said communication only occurs with authorized computer stations.

33. The method of claim 32, said securing communication step further including:

generating messages requesting security information from one said plurality of said computer stations with which communication is being established;

determining whether data messages received from said one said of plurality of computer stations in response to said data messages requesting security information indicates said one of said plurality of computer stations is authorized for communication; and

terminating said communication with said one of plurality of computer stations in response to determining said one computer station is unauthorized for communication.

34. The method of claim 33, said processing step further comprising communicating with at least two of said computer stations in a ANSI 837 format.

35. The method of claim 34, said processing step further comprising:

communicating with said at least two computer stations in said ANSI 837 format differently.

36. The method of claim 33, said processing step further comprising:

communicating with at least two of said plurality of computer stations in an ANSI 835 format.

37. The method of claim 36, said processing step further comprising:

communicating with said two of said plurality of said computer stations in said ANSI 835 format differently.

38. The method of claim 29, the processing step further comprising:

converting said error record to an error message having a format corresponding to said computer station identified in said error record; and

transmitting said error message to said identified computer station.

39. The method of claim 38, said processing step further comprising:

examining said patient care records to determine whether said record contains remittance information;

generating electronic funds transfer messages in response to said remittance information; and

formatting said electronic funds transfer messages in a format that corresponds to one of said computer station identification codes.

40. The method of claim 39, said processing step further including:

providing a line of credit at one of a financial institution and credit processor having one of said plurality of computer stations;

determining from a patient care record containing remittance information that a portion of a medical claim was not paid;

generating credit authorization messages for said financial institution and said credit processor having said credit line for requesting whether sufficient funds exist in said credit line to pay said uncovered portion of said medical claim;

generating electronic funds transfer messages in response to messages from said financial institution and said credit processor that indicate sufficient credit is available for paying said uncovered portion of said medical claim; and

transmitting said electronic funds transfer messages to pay said uncovered portion of said medical claim.

41. The method of claim 29, said processing step further comprising:

storing said patient care records in a patient care transaction database; and

storing said error records in said patient care transaction database.

42. The method of claim 41, said processing step further comprising:

statistically analyzing said patient care transaction database so that information may be derived for studying the medical claims, records, and remittance information records communicated by said plurality of said computer stations.