Automated system and method for providing real-time verification of health insurance eligibility

• US 5,832,447 A
• Filed: 05/24/1994
• Issued: 11/03/1998
• Est. Priority Date: 05/24/1994
• Status: Expired due to Term

• Current Assignee: Envoy LLC (UnitedHealth Group Incorporated)
• Original Assignee: Envoy Corporation (IQVIA Holdings, Inc.)
• Inventors: Mansfield, Daniel K., Rieker, Edward C.
• Primary Examiner(s): Hayes, Gail O.
• Assistant Examiner(s): GROUTT, PHILLIP J
• Application Number:
  US08/248,459
• Time in Patent Office: 1,624 Days
• Field of Search: 364/401, 364/413.01, 364/413.02, 235/378, 235/380, 235/375, 235/494, 395/200.01, 395/670, 395/200.3
• US Class Current: 705/2
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

Data from a health care provider computer system is used to automatically request real-time electronic insurance eligibility verification information from health care insurance payors. A patient health insurance verification computer system is operatively connected to a patient registration computer system. The verification computer system obtains a data output stream such as a print image from the registration computer system. This data output stream is captured and broken down into separate data fields. The insurance carrier is determined, and the verification computer system determines which electronic data source to request patient eligibility data from. The verification computer system reformats the captured data to fit the data format required by the data source, establishes a communications link to the data source, and sends the reformatted data to the data source. The data source sends responsive patient specific eligibility data which the verification computer system uses to automatically verify insurance coverage. Health insurance verification becomes much more reliable since no human intervention is required to carry on the automatic verification process. Additionally, automatic verification can be performed conveniently without double data entry even in environments with preexisting admissions systems that cannot be easily modified.

Claims

1. In a medical facility that utilizes an existing computerized healthcare patient registration computer system to input patient information and register patients for healthcare services, the existing computerized healthcare patient registration computer system lacking the capability to reliably verify patient health insurance coverage information in real time, the existing computerized healthcare patient registration computer system generating a digital output stream based at least in part on patient information inputted into the computerized healthcare patient registration computer system, the digital output stream including declared insurance provider information, a method of automatically, without requiring direct human intervention, verifying patient health insurance information using a patient health insurance verification computer system operatively connected to the existing computerized healthcare patient registration computer system, the method comprising the following steps:

(a) inputting, into the computerized healthcare patient registration computer system, information relating to a patient to be registered with a health care provider;

(b) based at least in part on said information inputted by the inputting step (a), generating a digital output stream with the computerized healthcare patient registration computer system and sending the digital output stream to an output device connected as part of the computerized healthcare patient registration computer system;

(c) capturing, with the patient health insurance verification computer system operatively connected to the computerized healthcare patient registration computer system, the digital output stream the computerized healthcare patient registration computer system generates in step (b), and extracting at least some patient related information including said declared insurance provider information from said digital output stream;

(d) generating, with the patient health insurance verification computer system, a digital insurance verification request message that is formatted based at least in part on said extracted declared insurance provider patient related information;

(e) communicating said digital insurance verification request message from the patient health insurance verification computer system to at least one data source located remotely from the patient health insurance verification computer system; and

(f) receiving, with the patient health insurance verification computer system from the remotely located data source, a digital insurance verification response message in response to said communicated request message.

3. A method as in claim 1 wherein step (c) comprises intercepting a print digital output stream the computerized healthcare patient registration computer sends to a printer attached thereto.

4. A method as in claim 1 wherein step (c) comprises intercepting the digital output stream from a data tap connected between the computerized healthcare patient registration computer and the output device.

5. A method as in claim 1 further including the step of selecting, based on the extracted patient related information, a data source from a set of multiple data sources;

and

wherein the communicating step (e) comprises;

(e1) establishing a telecommunications connection to the selected data source, and

(e2) communicating the digital insurance verification request message to the selected data source over the telecommunications connection established by step (e1).

6. A method as in claim 5 further including the steps of:

maintaining, with the patient health insurance verification computer system, a list of the multiple data sources within the set;

establishing a further telecommunications connection between the patient health insurance verification computer system and a further computer remote thereto; and

updating, with the further computer over the established further telecommunications connection, the list of multiple data sources.

7. A method as in claim 1 further including the step of determining an insurance carrier based on the extracted patient related information, and wherein the generating step (d) includes the step of formatting the digital insurance verification message in a predetermined manner associated with the determined insurance carrier.

8. A method as in claim 1 wherein step (e) is performed in real time with performance of step (a).

9. A method as in claim 1 wherein step (c) comprises extracting at least the patient'"'"'s name and insurance carrier identification from the digital output stream, and generating step (d) comprises selecting a predetermined digital insurance verification request message format based at least in part on the extracted insurance carrier identification.

10. A method as in claim 1 wherein the step (c) comprises extracting at least the patient'"'"'s name and insurance carrier identification from the digital output stream, and communicating step (e) comprises using a predetermined digital insurance verification request message communications protocol selected based at least in part on the extracted insurance carrier identification.

11. A method as in claim 1 wherein steps (c)-(f) are performed without requiring any human interaction.

12. A method as in claim 1 wherein the method further includes:

(g) maintaining communications information specifying how to communicate with plural data sources, and

(h) remotely updating the communications information maintained by step (g); and

wherein communicating step (e) includes the step of using at least some of the maintained communications information to communicate the digital insurance verification request message.

13. A method as in claim 1 wherein steps (a)-(d) are repeated for plural different patients to generate plural corresponding different digital insurance verification request messages, and step (e) communicates a batch comprising the plural different digital insurance verification request messages to the data source.

14. A method as in claim 1 wherein step (c) includes the step of extracting at least three of the following data items from the digital output stream:

(1) patient identification;

(2) patient date of birth;

(3) patient sex;

(4) benefit code;

(5) insured identification; and

(6) payor identification.

15. A method as in claim 1 wherein step (e) is performed concurrently to communicate multiple digital insurance verification request messages to plural different data sources.

16. A method as in claim 1 further including:

(g) maintaining a log of digital insurance verification request messages generated by step (d); and

(h) accessing the log to prevent redundant digital insurance verification request messages from being communicated.

17. A method as in claim 1 wherein step (f) comprises the step of receiving, within the digital insurance verification response message, at least one of:

information concerning particular benefits packages,

an indication of whether the health care provider is a member of the patient'"'"'s managed care group, and

copayment arrangements.

2. In a medical facility that utilizes an existing computerized healthcare patient registration computer system to input patient information, the existing computerized healthcare patient registration computer system being used to register patients for healthcare services, the existing computerized healthcare patient registration computer system lacking the capability to reliably verify patient health insurance information in real time, the computerized healthcare patient registration computer system generating digital output signals based at least in part on patient information inputted into the computerized healthcare patient registration computer system, the digital output signals providing patient related information including a declared insurance provider, a method of automatically, without requiring direct human intervention, verifying patient health insurance information using a patient health insurance verification computer system operatively connected to the existing computerized healthcare patient registration computer system, the method comprising the following steps:

(a) operatively connecting a patient health insurance verification computer system to the computerized healthcare patient registration computer system;

(b) capturing at least some patient related information including the declared insurance provider from the digital output signals generated by the computerized healthcare patient registration computer system,

(c) generating a digital verification request message based at least in part on said captured patient related information, including the step of formatting the digital verification request message based at least in part on said declared insurance provider;

(d) communicating said digital verification request message to a verification institution;

(e) receiving a digital verification response message in response to said communicated digital verification request message;

(f) providing an indication of at least one aspect of said patient'"'"'s health insurance to said patient'"'"'s health care provider in response to said received response message; and

(g) discharging said patient from said health care provider some time after said step (f) has been performed.

18. Apparatus for automatically verifying patient health insurance information in a health care facility having an existing computerized healthcare patient registration computer system including at least one output device connected thereto, the computerized healthcare patient registration computer system being used to register patients for healthcare services by inputting information relating to a patient to be registered with a health care provider, the existing computerized healthcare patient registration computer system lacking the capability to reliably verify patient health insurance coverage information in real time, the computerized healthcare patient registration computer system generating a digital output stream including a declared insurance provider based at least in part on said inputted information, and sending the digital output stream to the output device, the apparatus comprising a patient health insurance verification computer system operatively connected to the existing computerized healthcare patient registration computer system, the patient health insurance verification computer system automatically verifying patient health insurance information without requiring direct human intervention, the patient health insurance verification computer system including:

a capture subsystem that obtains the digital output stream generated by the existing computerized healthcare patient registration computer system and extracts at least some patient related information including the declared insurance provider from said digital output stream,

a communications subsystem that generates a digital insurance verification request message formatted based at least in part on said extracted declared insurance provider patient related information, communicates said digital insurance verification request message from the patient health insurance verification computer system to at least one data source located remotely from the patient health insurance verification computer system, and receives, from the remotely located data source, a digital insurance verification response message in response to said communicated request message, and

an indicating subsystem that provides a humanly readable indication of the received digital insurance verification response message.