Provider claim editing and settlement system

• US 6,341,265 B1
• Filed: 12/03/1998
• Issued: 01/22/2002
• Est. Priority Date: 12/03/1998
• Status: Expired due to Term

• Current Assignee: PPS Data LLC (Zions Bancorporation, N.A.)
• Original Assignee: P5 Ehealth Services Incorporated
• Inventors: Provost, Wayne A., Peterson, Brian E., Cecil, Vaughn C., Kwant, John W. Jr.
• Primary Examiner(s): RIMELL, SAMUEL G
• Application Number:
  US09/204,886
• Time in Patent Office: 1,146 Days
• Field of Search: 705/3, 705/4, 705/2, 705/1, 709/201, 709/203, 709/219
• US Class Current: 705/4
• 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
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: Y10S 707/99945 Object-oriented database structure processing
• CPC Class Codes: Y10S 707/99948 Application of database or data structure, e.g. distributed, multimedia, or image

Abstract

Methods and systems for interactively creating and submitting insurance claims and determining whether the submitted claims are in condition for payment by an insurer. A medical technician operating a client computer establishes communication with a remote server. The remote server transmits a claim form to the client computer for display to the medical technician. Using the claim form, the technician enters patient identification information, which is transmitted to the server to determine whether the patient is a beneficiary of an approved insurance plan. If the patient is a beneficiary, the technician can prepare an insurance claim using the claim form displayed by the client computer. The technician enters a diagnosis code and a treatment code representing the diagnosis and treatment of the patient. The diagnosis and treatment codes are transmitted to the remote server, which processes the codes to determine whether the claim corresponds to health care services that are approved for payment. If the insurance claim is not in condition for payment, the medical technician is notified. The medical technician can then amend the insurance claim as necessary and resubmit the claim.

Claims

1. In a system comprising a client computer and a remote server computer connected to the client computer by a communication link, a method of interactively preparing an insurance claim in preparation for a health care provider to perform health care services, the method comprising the steps of:

entering, by a health care provider, a diagnosis code and a treatment code to a computer-displayable claim form displayed by the client computer;

transmitting the diagnosis code and the treatment code from the client computer to the remote server computer prior to the health care provider performing health care services;

determining, at a processor associated with the remote server computer, that the diagnosis code and the treatment code do not correspond to health care services that are approved for payment;

transmitting information from the remote server computer to the client computer, the information indicating to the health care provider that the diagnosis code and the treatment code do not correspond to health care services that are approved for payment prior to the health care provider performing the health care services; and

transmitting, from the remote server computer to the client computer, a suggested revised treatment code prior to the health care provider performing the health care services, such that the treatment associated with the revised treatment code can be included in the health care services when the health care services are performed by the health care provider.

2. A method as defined in claim 1, wherein the computer-displayable form is a hypertext markup language document.

3. A method as defined in claim 1, wherein the step of transmitting the diagnosis code and the treatment code and the step of transmitting information are both conducted within a single period of time that is short enough so that the health care provider continues to view the computer-displayable form during the single period of time.

4. A method as defined in claim 1, wherein the step of transmitting the diagnosis code and the treatment code and the step of transmitting information are both conducted within a single period of time that is short enough so that the communication between the remote server computer and the client computer is not discontinued during the single period of time.

5. A method as defined in claim 1, wherein the diagnosis code and the treatment code are associated with a first patient, the method further comprising the steps of:

entering, by a health care provider, a second diagnosis code and a second treatment code to the claim form;

transmitting the second diagnosis code and the second treatment code from the client computer to the remote server computer;

determining, at the processor, whether the second diagnosis code and the second treatment code correspond to health care services that are approved for payment; and

transmitting further information from the remote server computer to the client computer, the further information indicating to the health care provider whether the second diagnosis code and the second treatment code correspond to health care services that are approved for payment.

6. A method as defined in claim 1, further comprising the step of transmitting, from the remote server computer to the client computer, data representing an amount to be paid by an insurer to a health care provider who is to perform the health care services.

7. A method as defined in claim 6, further comprising the step of displaying, by the client computer, co-payment information representing a co-payment to be collected from a patient who has received the health care services.

8. A method as defined in claim 7, further comprising the step of collecting the co-payment from the patient based on the co-payment information.

9. A method as defined in claim 8, wherein the step of collecting the co-payment from the patient is conducted during a visit of the patient to an office of the health care provider, wherein the patient receives said health care services during said visit.

10. In a system that includes a remote server computer and a client computer capable of communicating with the remote server computer, a method of interactively preparing an insurance claim comprising the steps of:

generating a computer-displayable claim form for display to a health care provider;

receiving a diagnosis code and a treatment code entered to the claim form by the health care provider;

initiating transmission of the diagnosis code and the treatment code from the client computer to the remote server computer prior to the health care provider performing health care services associated with the treatment code;

receiving information from the remote server computer indicating to the health care provider that the diagnosis code and treatment code do not correspond to health care services that are approved for payment prior to the health care provider performing the health care services associated with the treatment code; and

receiving, from the remote server computer, a suggested revised treatment code prior to the health care provider performing the health care services, such that the treatment associated with the revised treatment code can be included in the health care services when the health care services are performed by the health care provider.

11. A method as defined in claim 10, wherein the step of transmitting the diagnosis code and the treatment code and the step of transmitting information are both conducted within a single period of time that is short enough so that the communication between the remote server computer and the client computer is not discontinued during the single period of time.

12. A method as defined in claim 10, further comprising, before the step of receiving the diagnosis code and the treatment code, the step of transmitting patient identification information from the client computer to the remote server computer.

13. A method as defined in claim 12, further comprising, after the step of transmitting patient identification information and prior to the health care provider performing the health care services, the step of receiving verification from the remote server computer that a patient identified by the patient identification information is a beneficiary of a health insurance plan.

14. In a system that includes a client computer and a server system capable of communicating with the client computer, a method of informing a health care provider using the client computer whether an insurance claim represents health care services that are approved for payment prior to the health care provider performing the health care services, comprising the steps of:

receiving a treatment code and a diagnosis code from the client computer, the treatment code and diagnosis code having been entered to the client computer by a health care provider prior to the health care provider performing health care services;

examining the treatment code and the diagnosis code and determining that the treatment code and the diagnosis code do not correspond to health care services that are approved for payment;

initiating transmission of information to the client computer indicating to the health care provider indicating that the treatment code and the diagnosis code do not correspond to health care services that are approved for payment prior to the health care provider performing the health care services, such that the health care provider can base a decision regarding whether to perform the health care services on whether the health care services are approved for payment; and

initiating transmission of a suggested revised treatment code to the client computer prior to the health care provider performing the health care services, such that the treatment associated with the revised treatment code can be included in the health care services when the health care services are performed by the health care provider.

15. A method as defined in claim 14, further comprising, prior to the step of receiving the treatment code and the diagnosis code, transmitting a computer-displayable claim form to the client computer for display to the health care provider, the claim form including fields for accepting the treatment code and the diagnosis code.

16. A method as defined in claim 15, wherein the step of transmitting a computer-displayable claim form comprises the step of transmitting a hypertext markup language document from to the client computer via the Internet.

17. A method as defined in claim 14, wherein the step of receiving the diagnosis code and the treatment code and the step of transmitting information are both conducted within a single period of time that is short enough so that communication between the remote server computer and the client computer is not discontinued during the single period of time.

18. A method as defined in claim 14, wherein the step of examining the treatment code and the diagnosis code comprises the step of comparing the treatment code and the diagnosis code to a database having entries that represent currently accepted medical practice.

19. A method as defined in claim 14, wherein the step of examining the treatment code and the diagnosis code comprises the step of determining whether a plurality of treatment codes is consistent with an unbundling claiming practice.

20. A computer program product for implementing a method of interactively preparing an insurance claim prior to a health care provider performing health care services that are the subject of the insurance claim, wherein the method is capable of being performed on a client computer that communicates with a remote server computer, the computer program product comprising:

a computer-readable medium carrying computer-executable instructions for implementing the method, the computer-executable instructions comprising;

program code means for displaying a computer-displayable claim form to a health care provider;

program code means for initiating transmission of a diagnosis code and a treatment code from the client computer to the remote server computer prior to the health care provider performing the health care services;

program code means for receiving, from the remote server computer and prior to the health care provider performing the health care services, information indicating that the diagnosis code and the treatment code do not correspond to health care services that are approved for payment; and

program code means for receiving, from the remote server computer, a suggested revised treatment code prior to the health care provider performing the health care services, such that the treatment associated with the revised treatment code can be included in the health care services when the health care services are performed by the health care provider.

21. A computer program product as defined in claim 20, wherein the program code means for initiating transmission of the diagnosis code and the treatment code comprise program code means for communicating with the remote server via the Internet.

22. A computer program product as defined in claim 21, wherein the program code means for communicating with the remote server via the Internet operate so as to maintain communication with the remote server during a time period between the transmission of the diagnosis code and the treatment code and the receipt of the information from the remote server computer.

23. A computer program product for implementing, in a server system that communicates with a client system, a method of informing a health care provider who uses the client computer whether an insurance claim represents health care services approved for payment prior to the health care provider performing the health care services, the computer program product comprising:

a computer-readable medium carrying computer-executable instructions for implementing the method, the computer-executable instructions comprising;

program code means for receiving a treatment code and a diagnosis code from the client computer, the treatment code and diagnosis code having been entered to the client computer by a health care provider prior to the health care provider performing health care services;

program code means for determining whether the treatment code and the diagnosis code correspond to health care services that are approved for payment; and

program code means for initiating transmission of information to the client computer indicating to the health care provider that the treatment code and the diagnosis code do not correspond to health care services that are approved for payment prior to the health care provider performing the health care services, such that the health care provider can base a decision regarding whether to perform the health care services on whether the health care services are approved for payment; and

program code means for initiating transmission of a suggested revised treatment code, to the client computer, prior to the health care provider performing the health care services, such that the treatment associated with the revised treatment code can be included in the health care services when the health care services are performed by the health care provider.

24. A computer program product as defined in claim 23, wherein the computer-executable instructions further comprise program code means for initiating transmission of a computer-displayable claim form to the client computer, the claim form including fields for accepting the treatment code and the diagnosis code.

25. A computer program product as defined in claim 23, wherein the computer-executable instructions further comprise:

program code means for receiving patient identification information from the client computer, the patient identification information identifying an patient of the health care provider;

program code means for determining whether the patient is a beneficiary of a health insurance plan; and

program code means for initiating transmission of data to the client computer indicating whether the patient is a beneficiary of a health insurance plan prior to the health care provider performing the health care services for the patient.

26. A computer program product as defined in claim 25, wherein the program code means for receiving patient identification information and the program code means for initiating transmission of data operate by communicating with the client computer via the Internet.

27. A computer program product as defined in claim 26, wherein the computer-executable instructions further comprise program code means for maintaining communication with the client computer during a time period between the receipt of the diagnosis code and the treatment code and the transmission of the information to the client computer.