System for exchanging health care insurance information

• US 5,890,129 A
• Filed: 05/30/1997
• Issued: 03/30/1999
• Est. Priority Date: 05/30/1997
• Status: Expired due to Fees

• Current Assignee: Loren J. Spurgeon
• Original Assignee: Loren J. Spurgeon
• Inventors: Spurgeon, Loren J.
• Primary Examiner(s): Peeso, Thomas R.
• Application Number:
  US08/865,719
• Time in Patent Office: 669 Days
• Field of Search: 705/2, 705/3, 705/4, 395/200.32, 395/200.47, 395/200.33, 707/1, 707/10, 707/102, 707/200
• US Class Current: 705/4
• CPC Class Codes: B42D 15/00 Printed matter of special format or style not otherwise provided for
• CPC Class Codes: B42D 15/042 Foldable cards or sheets B42D15/045 and B42D15/08 take precedence
• CPC Class Codes: G06Q 30/0601 Electronic shopping [e-shopping]
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 40/12 Accounting
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: Y10S 707/99931 Database or file accessing
• CPC Class Codes: Y10S 707/99943 Generating database or data structure, e.g. via user interface

Abstract

An information-exchange system is provided for controlling the exchange of business and clinical information between an insurer and multiple health care providers. The system includes an information-exchange computer that is connected over a local area network to an insurer computer using a proprietary database and over the Internet to health-care provider computers using open database-compliant databases. The information-exchange computer receives subscriber insurance data from the insurance computer database, translates the insurance data into an exchange database, and pushes the subscriber insurance data out over the Internet to the computer operated by the health-care provider assigned to each subscriber. The information-exchange system stores the data in the provider database. The information-exchange system also provides for the preparation, submission, processing, and payment of claims over the local area network and with push technology over the Internet. In addition, prior authorization requests may be initiated in the provider computers and exchanged over the information-exchange system for review by the insurer computer. Processed reviews are transmitted back to the provider computer and to a specialist computer, if required, using push technology over the Internet.

Claims

1. A system for controlling the exchange of information between an insurer and multiple health care providers in a health care delivery system, where each health care provider is assigned a subgroup of subscribers from a group of subscribers within the insurer'"'"'s health plan, the system comprising:

an insurer computer configured to maintain an insurer database of subscriber insurance data on the group of the insurer'"'"'s subscribers, the database having a first predetermined format;

an information-exchange computer operatively connected to the insurer computer to receive at least some subscriber insurance data on the group of the insurer'"'"'s subscribers therefrom, the information-exchange computer being configured to store that subscriber insurance data in an exchange database in a second predetermined format that is different from the first predetermined format; and

plural provider interface computers located at plural corresponding health care providers offices, each provider interface computer being operatively connected to the information-exchange computer to receive therefrom and store in a provider database subscriber insurance data for the subgroup of subscribers assigned to the provider, where changes in subscriber insurance data for each subgroup stored in the insurer computer are automatically transmitted to the information-exchange computer and then forwarded to the provider interface computer corresponding to the provider to whom the subgroup is assigned, to thereby automatically maintain the currency of the provider database as the subscriber insurance data changes.

2. The system of claim 1 wherein the subscriber insurance data are transmitted from the information-exchange computer to the first provider interface computer using push technology.

3. The system of claim 1 further comprising plural practice management system applications corresponding to the plural provider interface computers wherein the subscriber insurance data stored in each provider database are translated automatically and transmitted to each practice management system.

4. The system of claim 3 wherein at least one of the practice management system applications is operable on a practice management computer.

5. The system of claim 4 wherein the practice management computer communicates with the corresponding provider interface computer over a provider local area network.

6. The system of claim 3 wherein at least one of the practice management system applications is operable on one of the provider interface computers.

7. The system of claim 1 wherein the insurer database and at least one of the provider databases are mutually incompatible.

8. The system of claim 7 wherein the exchange database is ODB-compliant.

9. The system of claim 8 wherein the insurer database is not ODB-compliant.

10. The system of claim 7 wherein the exchange database is an SQL database.

11. The system of claim 10 wherein the insurer database is not an SQL database.

12. The system of claim 1 wherein at least two of the practice management systems have differing formats for the subscriber insurance data.

13. The system of claim 1 wherein at least one of the provider interface computers is configured to receive subscriber insurance data from a second information-exchange computer.

14. A system for exchanging information between an insurer providing insurance coverage to a subscriber for medical care at a health care provider, the subscriber being assigned to the health care provider and the data being exchanged over an insurer local area network and a network using an open communications protocol, the system comprising:

a first practice management system application configured to assemble claims;

a first provider computer capable of communicating on the open network, the first provider computer being configured to receive the claims from the first practice management system application, to store the claims in a first provider database and to transmit the claims over the open network;

an information-exchange computer capable of communicating on the insurer local area network and the open network, the information-exchange computer being configured to receive the claims from the first provider computer over the open network, to store the claims in an exchange database and to automatically translate and transmit the claims over the insurer local area network; and

an insurer computer capable of communicating on the insurer local area network, the insurer computer being configured to receive the claims from the information-exchange computer over the insurer local area network and to store the claims in an insurer database.

15. The system of claim 14 wherein the first practice management system application is operable on a practice management computer connected to the first provider computer by a provider local area network.

16. The system of claim 15 wherein the claims are transmitted from the first practice management computer to the first provider computer over the provider local area network in an ASCII flat file.

17. The system of claim 14 wherein the first practice management system application is operable on the first provider computer.

18. The system of claim 14 further comprising

a second practice management system application configured to assemble claims;

and

a second provider computer capable of communicating on the open network, the second provider computer being configured to receive the claims from the second practice management system application, to store the claims in a second provider database and to transmit the claims over the open network,

wherein the information-exchange computer is configured to receive the claims from the second provider computer over the open network, to store the claims in an information-exchange database and to automatically translate and transmit the claims over the insurer local area network.

19. The system of claim 14 wherein the first provider database and the insurer database are mutually incompatible.

20. The system of claim 14 wherein the provider interface computer transmits the claims over the open network via push technology.

21. A system for exchanging information between an insurer providing insurance coverage to a subscriber for medical care at a health care provider, the subscriber being assigned to the health care provider and the data being exchanged over an insurer local area network and a network using an open communications protocol, the system comprising:

a first provider computer capable of communicating on the open network, the first provider computer being configured to allow a user to prepare a prior authorization request;

an information-exchange computer capable of communicating on the insurer local area network and the open network, the information-exchange computer being configured to receive the prior authorization request from the first provider computer over the open network and to store the prior authorization request in the information-exchange computer in an exchange database; and

an insurer computer capable of communicating on the insurer local area network, the insurer computer being configured to receive the prior authorization from the information-exchange computer and to store the prior authorization in an insurer database,

wherein the prior authorizations stored in the exchange database are translated automatically to the insurer database.

22. The system of claim 21 wherein the insurer computer is further configured to transmit via push technology a processed prior authorization to the information-exchange computer.

23. The system of claim 22 wherein the information-exchange computer transmits the processed prior authorization to the first provider computer and wherein the first provider computer is further configured to receive the processed prior authorization and to store the response in the provider database.

24. The system of claim 21 further comprising a specialist computer configured to receive the processed prior authorization and wherein the information-exchange computer transmits the processed prior authorization to the specialist computer.