Methods for reducing fraud in healthcare programs using a smart card

• US 6,873,960 B1
• Filed: 05/22/2003
• Issued: 03/29/2005
• Est. Priority Date: 04/08/2003
• Status: Active Grant

• Current Assignee: Access Security Protection LLC
• Original Assignee: Richard Glee Wood, Wesley Jack Jr. White
• Inventors: Wood, Richard Glee, White, Wesley Jack Jr.
• Primary Examiner(s): Thomas, Joseph
• Assistant Examiner(s): Gilligan, Christopher L.
• Application Number:
  US10/443,194
• Time in Patent Office: 677 Days
• Field of Search: 705/2, 705/3, 705/4, 600/300
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/28 Pre-payment schemes, e.g. "pay before"
• CPC Class Codes: G06Q 20/342 Cards defining paid or billed services or quantities
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G07F 7/025 by means, e.g. cards, providing billing information at the time of purchase, e.g. identification of seller or purchaser, quantity of goods delivered or to be delivered

Abstract

Methods for reducing fraud in a prescription healthcare program are described herein. The methods generally include registering a service provider with a prescription healthcare provider and issuing a service provider identification code to the service provider and registering an item of the service provider with the prescription healthcare provider to create a registered item and identifying a claim code for each registered item. The item can include at least one service, at least one good and combinations thereof. The method further includes issuing a smart card to an person related to the prescription healthcare program, wherein the smart card has a smart card identification feature to identify the person and using the smart card to determine if the person is the authorized bearer of the smart card and is eligible for benefits from the prescription healthcare program. The method further includes using the smart card- to facilitate a first transmission from the service provider to the prescription healthcare provider. The method further includes using the smart card to facilitate the second transmission from the prescription healthcare provider to the service provider. In one embodiment, the method includes using the smart card to facilitate a second transmission from the service provider to the prescription healthcare provider.

Claims

1. A method for reducing fraud in a prescription healthcare program comprising:

a. registering a service provider with a prescription healthcare provider and issuing a service provider identification code to the service provider;

b. registering an item of the service provider with the prescription healthcare provider to create a registered item and identifying a claim code for each registered item, wherein each registered item is selected from the group consisting of at least one service, at least one good and combinations thereof;

c. issuing a smart card to a first person related to the prescription healthcare program, wherein the smart card has a smart card identification feature to identify the person;

d. using the smart card to determine if a second person;

i. is an authorized bearer of the smart card; and

ii. is eligible for a proposed item from the prescription healthcare program, wherein the proposed item is a registered item;

e. using the smart card to facilitate a first transmission from the service provider to the prescription healthcare provider, wherein the first transmission comprises;

i. the service provider identification code;

ii. a personal identification code;

iii. proposed item information selected from the group consisting of proposed item information for the second person, corresponding claim codes for the proposed item, a statement stating that the proposed item is available to be provided to the second person upon receipt of a second transmission and combinations thereof; and

iv. a confirmation request, wherein the confirmation request comprises;

1. a first query on whether the second person is eligible for the proposed item under the prescription healthcare program;

2. a second query for a validation that the proposed item is approved for the second person;

3. a third query on whether the service provider is eligible to render services or provide goods under the prescription healthcare program; and

4. a request to participate in an accelerated payment program for the proposed item;

iv. a claim codes list for proposed items to be rendered; and

vi. an accelerated payment request by the service provider to the prescription healthcare provider.

f. using the smart card to facilitate the second transmission from the prescription healthcare provider to the service provider, wherein the second transmission consists of;

i. whether the second person is eligible for the proposed item under the prescription healthcare program;

ii. the validation on whether the proposed item is approved for the second person;

iii. whether the service provider is eligible to render services under the prescription healthcare program;

iv. a determination on whether the accelerated payment program is available and, if available, an authorization for accelerated payment;

v. an authorization code to provide the proposed item;

vi. a first acknowledgement by the second person that information on the proposed item was provided to the second person by the service provider, wherein the information includes instructions on use of the proposed item; and

vii. a second acknowledgement that the proposed item has been received by the second person from the service provider.

2. The method of claim 1, wherein the prescription healthcare program comprises prescription drugs, prescription healthcare equipment or combinations thereof.

3. The method of claim 1, wherein the prescription healthcare provider is selected from the group consisting of an insurance company, a drug manufacturer, a healthcare equipment manufacturer, a drug distributor, a healthcare distributor, a physician and combinations thereof.

4. The method of claim 1, wherein the service provider is selected from the group consisting of a nursing home, a hospital, a clinic, a pharmacy, a physician, a physical therapist, a podiatrist, emergency medical technicians and combinations thereof.

5. The method of claim 1, wherein the second transmission further comprises an alert to the service provider that the second person is responsible for a first portion of funds required for the proposed item and an indication of the amount of the portion of the funds.

6. The method of claim 1, wherein the second transmission further comprises dollar amount limits for the accelerated payment.

7. The method of claim 1, wherein the second transmission further comprises a third requirement to create and retain a record that the first portion of the funds was collected from the second person by the service provider.

8. The method of claim 1, further comprising transmitting a second portion of funds from the prescription healthcare provider to the service provider, wherein the second portion of funds are transmitted within from 1 to 21 days of receipt of the first transmission by the prescription healthcare provider and acknowledgment of the availability of accelerated payment by the prescription healthcare provider in the second transmission.

9. The method of claim 1, wherein the prescription healthcare program is selected from the group consisting of Medicare, Medicaid, other federal health programs, private healthcare insurance programs, other private health programs and combinations thereof.

10. The method of claim 1, wherein the smart card identification feature is selected from the group consisting of a personal identification code, a biometrics identification system, personal data, government issued numbers and combinations thereof.

11. The method of claim 1, wherein the first transmission further comprises information selected from the group consisting of:

a. a first transmission identification code;

b. service provider information selected from the group consisting of;

i. a service provider code;

ii. a service provider name;

iii. a service provider address;

iv. a service provider office code;

v. a service provider phone number;

vi. and combinations thereof;

c. personal information selected from the group consisting of;

i. person'"'"'s name;

ii. person'"'"'s address;

iii. person'"'"'s phone number;

iv. person'"'"'s social security number,

v. person'"'"'s healthcare provider code;

vi. healthcare information selected from the group consisting of provider number, policy number, group number, employer information and combinations thereof;

vii. a date on which the proposed item was rendered;

viii. a total amount to be charged relative to the person;

ix. detail information describing the proposed item related to the claim codes for the registered item;

x. a request to update personal data on the person; and

ix. combinations thereof.

12. The method of claim 1, wherein the second transmission further comprises additional information selected from the group consisting of:

a. a depiction of the first person;

b. a second transmission identification code;

c. a statement as to any amount that exceeds an authorized cost of the proposed item;

d. verification of a request to update personal data on the person; and

e. combinations thereof.

13. The method of claim 1, wherein the smart card is an electronically readable card comprising smart card information selected from the group consisting of:

a. person'"'"'s name;

b. person'"'"'s address;

c. person'"'"'s phone number;

d. person'"'"'s fax number;

e. person'"'"'s email address;

f. person'"'"'s social security number;

g. prescription healthcare program name;

h. prescription healthcare program address;

i. prescription healthcare provider phone number;

j. prescription healthcare provider fax number;

k. prescription healthcare provider e-mail address;

l. prescription healthcare program administrator;

m. description of prescription healthcare provider benefit plan;

n. first portion of funds;

o. person'"'"'s benefit history;

p. other phone numbers;

q. instructions on how to contact the prescription healthcare provider;

r. expiration date of the smart card;

s. prescription healthcare provider website address;

t. a chip to obtain the smart card information on the prescription healthcare program;

u. personal data;

v. health information; and

w. combinations thereof.

14. The method of claim 1, wherein a benefit history of the first person includes information on length of time on prescription healthcare provider programs and types of other programs the person is eligible to use.

15. The method of claim 1, further comprising creating a contractual relationship between the prescription healthcare provider and the service provider for the benefit of the second person.

16. The method of claim 1, further comprising disposing marks on the smart card, wherein the marks are selected from the group consisting of the healthcare provider trademarks and logos, third party trademarks and logos, service provider trademarks and logos and combinations thereof.

17. The method of claim 1 further comprising entering the service provider identification code into an electronic retrieval system.

18. The method of claim 17, wherein the electronic retrieval system comprises a process selected from the group consisting of an internet query, an e-mail query, a network query, comparative information transfers and combinations thereof.

19. The method of claim 1, wherein the using the smart card to determine if the second person is the authorized bearer of the card comprises comparing first data obtained from the first person to second data obtained from the second person to obtain a verified identity.

20. A method for reducing fraud in a prescription healthcare program comprising:

a. registering a service provider with a prescription healthcare provider and issuing a service provider identification code;

b. registering at least service or good of the service provider with the prescription healthcare provider and identifying a claim code for each registered service or registered good;

c. issuing a smart card to a person related to the prescription healthcare program, wherein the smart card has a smart card identification feature to identify the person;

d. using the smart card to determine if the person;

i. is an authorized bearer of the card; and

ii. is eligible for a proposed service or good from the prescription healthcare program;

e. using the smart card to facilitate a first transmission from the service provider to the prescription healthcare provider, wherein the first transmission comprises;

i. a service provider identification code;

ii. a personal identification code;

iii. proposed service information selected from the group consisting of proposed product information for the person;

proposed service information for the person;

corresponding claim codes for the proposed product; and

corresponding claim codes for the proposed service; and

iv. a confirmation request, wherein the confirmation request comprises;

1. a first query on the person'"'"'s eligibility for the proposed good or service under the prescription healthcare program;

2. a second query for a validation that the proposed good or service is approved for the person;

3. a third query on the service provider'"'"'s eligibility to render services or provide goods under the prescription healthcare program; and

4. an optional request to participate in an accelerated payment program for the proposed good or the proposed service;

f. using the smart card to facilitate a second transmission from the prescription healthcare provider to the service provider, wherein the second transmission consists of;

i. the person'"'"'s eligibility for benefits under the prescription healthcare program;

ii. a validation that the proposed good or proposed service is approved for the person;

iii. a validation of the service provider'"'"'s eligibility to render services under the prescription healthcare program;

iv. an optional confirmation that an accelerated payment program is available; and

v. an authorization code to provide the proposed product and/or proposed service;

g. using the smart card to facilitate a third transmission from the service provider to the prescription healthcare provider, wherein the third transmission comprises;

i. a claim codes list for services rendered;

ii. acknowledgement by the person that service information on the product and/or service was provided to the person;

iv. acknowledgement that the product or service has been received from the service provider; and

v. a request for accelerated payment by the private healthcare provider to the service provider.