System and apparatus for utilization review of medical claims
First Claim
1. A medical cost containment system for allowing a medical cost payor to correlate medical bills from a medical service provider with utilization review (UR) agreements between said payor and said provider, said cost containment system comprising:
- a computer processor operatively coupled to a memory;
a UR database containing said UR agreements;
database access software stored within said memory, said database access software configured to allow retrieval of records from said UR database;
an invoice from said provider stored within said memory, said invoice having at least one itemized request for payment; and
correlation software stored within said memory, said correlation software configured to correlate said itemized request to said UR agreements;
said correlation software further configured to at least adjust an amount of said at least one itemized request for payment in accordance with said UR agreement or approve payment of at least one itemized request for payment in accordance with said UR agreement or flag at least one itemized request for payment for further review in accordance with said UR agreement.
4 Assignments
0 Petitions
Accused Products
Abstract
A medical cost containment system for ensuring that the anticipated cost savings from utilization review (UR) agreements are actually realized. The UR agreements are essentially contractual agreements that specify the type and quantity of medical treatments relating to a specific claim resulting from a specific injury. Each UR agreement comprises a claim number, a procedure code describing the particular medical service authorized, and some indication as to dates or quantity of service authorized. All of the UR agreements are stored in a UR database. When a medical bill is received by the insurance company, the bill is entered in to the computer. The cost containment system searches all UR agreements in the UR database which have the same claim number as the claim number on the bill. For each item in the medical bill, the system finds the UR agreement which most closely matches the procedure code in the line item and various other criteria, such as the dates of treatment. The system then checks to ensure that the item in the bill is authorized by the UR agreement. If the item is authorized, then payment is made. If the item is not authorized, then the item is flagged for further review.
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Citations
31 Claims
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1. A medical cost containment system for allowing a medical cost payor to correlate medical bills from a medical service provider with utilization review (UR) agreements between said payor and said provider, said cost containment system comprising:
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a computer processor operatively coupled to a memory;
a UR database containing said UR agreements;
database access software stored within said memory, said database access software configured to allow retrieval of records from said UR database;
an invoice from said provider stored within said memory, said invoice having at least one itemized request for payment; and
correlation software stored within said memory, said correlation software configured to correlate said itemized request to said UR agreements;
said correlation software further configured to at least adjust an amount of said at least one itemized request for payment in accordance with said UR agreement or approve payment of at least one itemized request for payment in accordance with said UR agreement or flag at least one itemized request for payment for further review in accordance with said UR agreement. - View Dependent Claims (2, 3, 4, 5, 6)
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7. A medical cost containment system for allowing a medical cost payor to correlate medical bills from a medical service provider with utilization review (UR) agreements between said payor and said provider, said cost containment system comprising:
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a computer processor operatively coupled to a memory;
a UR database containing said UR agreements;
database access software stored within said memory, said database access software configured to allow retrieval of records from said UR database;
an invoice from said provider stored within said memory, said invoice having at least one itemized request for payment; and
correlation software stored within said memory, said correlation software configured to determine a probability of correlation between each of said itemized requests and each of said UR agreements;
said correlation software further configured to at least adjust an amount of said at least one itemized request for payment in accordance with said UR agreement or approve payment of at least one itemized request for payment in accordance with said UR agreement or flag at least one itemized request for payment for further review in accordance with said UR agreement.
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8. A method for attempting to ensure that, in a managed care system, a utilization review (UR) agreement for medical services is properly enforced such that an anticipated cost savings under said UR agreement are realized, said method comprising the steps of:
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storing said UR agreement in a computerized UR database;
entering an itemized request for payment from a bill for medical services into a computer;
correlating said UR agreement with said itemized request for payment;
determining whether said itemized request for payment is proper under said UR agreement; and
adjusting an amount of said at least one itemized request for payment in accordance with said UR agreement or approving payment of at least one itemized request for payment in accordance with said UR agreement or flagging at least one itemized request for payment for further review in accordance with said UR agreement. - View Dependent Claims (9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19)
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20. A method for correlating imperfect matches between coded service items in a bill and a service authorization agreement, said method comprising the steps of:
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storing said service authorization agreement in a computerized agreement database;
entering into a computer an itemized request for payment from said bill;
correlating said service authorization agreement with said itemized request for payment; and
determining whether said itemized request for payment is proper under said service authorization agreement. - View Dependent Claims (21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31)
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Specification