Method of adjudicating medical claims based on scores that determine medical procedure monetary values

• US 6,879,959 B1
• Filed: 01/21/2000
• Issued: 04/12/2005
• Est. Priority Date: 01/21/2000
• Status: Expired due to Term

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Quality Care Solutions, Inc. (Cognizant Technology Solutions Corp.)
• Inventors: Echeverria, J. Mikel, Chapman, Sherwood
• Primary Examiner(s): Thomas, Joseph
• Assistant Examiner(s): Kapadia, Milan
• Application Number:
  US09/489,614
• Time in Patent Office: 1,908 Days
• Field of Search: 705/23, 705/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Claims

1. A method of adjudicating a medical claim comprising:

providing a first plurality of requirements for a first claim;

providing a second plurality of requirements for a second claim wherein the second claim has a higher monetary value than the first claim;

electronically receiving the medical claim for a medical procedure;

setting a first score for the first claim to an initial value;

setting a second score for the second claim to the initial value;

electronically comparing a plurality of components of the medical claim to the first and second pluralities of requirements;

electronically changing the first score in a first manner for each one of the plurality of components that match one of the first plurality of requirements;

electronically changing the first score in a second manner for each one of the first plurality of requirements that is missing from the plurality of components;

electronically changing the second score in the first manner for each one of the plurality of components that match one of the second plurality of requirements;

electronically changing the second score in the second manner for each one of the second plurality of requirements that is missing from the plurality of components; and

electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of the medical procedure for a medical service provider associated with the medical procedure,

wherein electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine the monetary value of the medical procedure for the medical service provider associated with the medical procedure further comprises;

if the first score was changed only in the first manner and if the second score was changed in the second manner, settling the medical claim as the first claim;

if the first score was changed in the second manner and if the second score was changed only in the first manner, settling the medical claim as the second claim;

if the first and second scores were changed only in the first manner and;

if the first score is further away in the first manner from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first manner from the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the first claim; and

if the first and second scores were changed in the second manner and;

if the first score is further away in the first manner from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first manner from the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the first claim.

2. The method of claim 1 wherein:

electronically changing the first score in the first manner further comprises adding a first positive value to the first score for each one of the plurality of components that match one of a first portion of the first plurality of requirements; and

electronically changing the second score in the first manner further comprises adding the first positive value to the second score for each one of the plurality of components that match one of a first portion of the second plurality of requirements.

3. The method of claim 2 wherein:

electronically changing the first score in the first manner further comprises adding a second positive value greater than the first positive value to the first score for each one of the plurality of components that match one of a second portion of the first plurality of requirements; and

electronically changing the second score in the first manner further comprises adding the second positive value to the second score for each one of the plurality of components that match one of a second portion of the second plurality of requirements.

4. The method of claim 3 wherein:

electronically changing the first score in the second manner further comprises subtracting the first positive value from the first score for each one of the first portion of the first plurality of requirements that is missing from the plurality of components; and

electronically changing the second score in the second manner further comprises subtracting the first positive value from the second score for each one of the first portion of the second plurality of requirements that is missing from the plurality of components.

5. The method of claim 4 wherein:

electronically changing the first score in the second manner further comprises subtracting the second positive value from the first score for each one of the second portion of the first plurality of requirements that is missing from the plurality of components; and

electronically changing the second score in the second manner further comprises subtracting the second positive value from the second score for each one of the second portion of the second plurality of requirements that is missing from the plurality of components.

6. The method of claim 1 wherein:

electronically receiving the medical claim for a medical procedure comprises;

receiving the medical claim for the medical procedure via the Internet.

7. A method of adjudicating a medical claim comprising:

providing a first plurality of requirements for a first claim;

providing a second plurality of requirements for a second claim wherein the second claim has a higher monetary value than the first claim;

electronically receiving the medical claim for a medical procedure;

setting a first score for the first claim to an initial value;

setting a second score for the second claim to the initial value;

electronically comparing a plurality of components of the medical claim to the first and second pluralities of requirements;

electronically changing the first score in a first manner for each one of the plurality of components that match one of the first plurality of requirements;

electronically changing the first score in a second manner for each one of the first plurality of requirements that is missing from the plurality of components;

electronically changing the second score in the first manner for each one of the plurality of components that match one of the second plurality of requirements;

electronically changing the second score in the second manner for each one of the second plurality of requirements that is missing from the plurality of components; and

electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of medical coverage for a patient associated with the medical procedure,

wherein electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of medical coverage for a patient associated with the medical procedure further comprises;

if the first score was changed only in the first manner and if the second score was changed in the second manner, settling the medical claim as the first claim;

if the first score was changed in the second manner and if the second score was changed only in the first manner, settling the medical claim as the second claim;

if the first and second scores were changed only in the first manner and;

if the first score is further away in the first manner from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first manner from the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the second claim; and

if the first and second scores were changed in the second manner and;

if the first score is further away in the first manner from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first manner from the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the second claim.

8. The method of claim 7 wherein:

electronically changing the first score in the first manner further comprises adding a first positive value to the first score for each one of the plurality of components that match one of a first portion of the first plurality of requirements; and

electronically changing the second score in the first manner further comprises adding the first positive value to the second score for each one of the plurality of components that match one of a first portion of the second plurality of requirements.

9. The method of claim 8 wherein:

electronically changing the first score in the first manner further comprises adding a second positive value greater than the first positive value to the first score for each one of the plurality of components that match one of a second portion of the first plurality of requirements; and

electronically changing the second score in the first manner further comprises adding the second positive value to the second score for each one of the plurality of components that match one of a second portion of the second plurality of requirements.

10. The method of claim 9 wherein:

electronically changing the first score in the second manner further comprises subtracting the first positive value from the first score for each one of the first portion of the first plurality of requirements that is missing from the plurality of components; and

electronically changing the second score in the second manner further comprises subtracting the first positive value from the second score for each one of the first portion of the second plurality of requirements that is missing from the plurality of components.

11. The method of claim 10 wherein:

electronically changing the first score in the second manner further comprises subtracting the second positive value from the first score for each one of the second portion of the first plurality of requirements that is missing from the plurality of components; and

electronically changing the second score in the second manner further comprises subtracting the second positive value from the second score for each one of the second portion of the second plurality of requirements that is missing from the plurality of components.

12. A method of adjudicating a medical claim comprising:

providing a first plurality of requirements for a first claim;

providing a second plurality of requirements for a second claim wherein the second claim has a higher monetary value than the first claim;

electronically receiving the medical claim for a medical procedure;

setting a first score for the first claim to an initial value;

setting a second score for the second claim to the initial value;

electronically comparing a plurality of components of the medical claim to the first and second pluralities of requirements;

electronically changing the first score in a first direction for each one of the plurality of components that match one of the first plurality of requirements;

electronically changing the first score in a second direction for each one of the first plurality of requirements that is missing from the plurality of components;

electronically changing the second score in the first direction for each one of the plurality of components that match one of the second plurality of requirements;

electronically changing the second score in the second direction for each one of the second plurality of requirements that is missing from the plurality of components;

electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of the medical procedure for a medical service provider associated with the medical procedure; and

electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of medical coverage for a patient associated with the medical procedure,

wherein electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine the monetary value of the medical procedure for the medical service provider associated with the medical procedure further comprises;

if the first score was changed only in the first direction and if the second score was changed in the second direction, settling the medical claim as the first claim;

if the first score was changed in the second direction and if the second score was changed only in the first direction, settling the medical claim as the second claim;

if the first and second scores were changed only in the first direction and;

if the first score is further away in the first direction from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first direction from the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the first claim; and

if the first and second scores were changed in the second direction and;

if the first score is further away in the first direction from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first direction from;

the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the first claim.

13. The method of claim 12 further comprising:

providing a first plurality of optional conditions for the first claim;

providing a second plurality of optional conditions for the second claim;

electronically changing the first score by a first predetermined value for each one of the plurality of components that match one of the first plurality of optional conditions; and

electronically changing the second score by a second predetermined value for each one of the plurality of components that match one of the second plurality of optional conditions,

wherein;

electronically comparing the plurality of components of the medical claim further comprises electronically comparing the plurality of components to the first and second pluralities of optional conditions.

14. The method of claim 13 further comprising:

providing zero for the first and second predetermined values.

15. The method of claim 12 further comprising:

providing zero for the initial value.

16. The method of claim 12 wherein:

electronically changing the first score in the first direction further comprises adding a first value to the first score for each one of the plurality of components that match one of a first portion of the first plurality of requirements; and

electronically changing the second score in the first direction further comprises adding the first value to the second score for each one of the plurality of components that match one of a first portion of the second plurality of requirements.

17. The method of claim 16 wherein:

electronically changing the first score in the first direction further comprises adding a second value greater than the first value to the first score for each one of the plurality of components that match one of a second portion of the first plurality of requirements; and

electronically changing the second score in the first direction further comprises adding the second value to the second score for each one of the plurality of components that match one of a second portion of the second plurality of requirements.

18. The method of claim 17 wherein:

electronically changing the first score in the second direction further comprises subtracting the first value from the first score for each one of the first portion of the first plurality of requirements that is missing from the plurality of components; and

electronically changing the second score in the second direction further comprises subtracting the first value from the second score for each one of the first portion of the second plurality of requirements that is missing from the plurality of components.

19. The method of claim 18 wherein:

electronically changing the first score in the second direction further comprises subtracting the second value from the first score for each one of the second portion of the first plurality of requirements that is missing from the plurality of components; and

electronically changing the second score in the second direction further comprises subtracting the second value from the second score for each one of the second portion of the second plurality of requirements that is missing from the plurality of components.

20. The method of claim 19 further comprising:

providing zero for the initial value;

providing one for the first value; and

providing one hundred for the second value.

21. The method of claim 12 further comprising:

providing the first and second pluralities of requirements from the group consisting of at least one of;

whether the medical procedure is for early periodic screening diagnostic testing of minors;

whether and how much of the fee for the medical procedure is taken out of a risk pool of money;

whether the dates of the medical procedure occur between the effective date and the termination date of the medical contract;

whether a standard fee or a modified fee is used, and the difference between these two types of fees;

whether the patient falls within any applicable age restrictions;

whether the fee for the medical procedure falls under a capitation schedule;

whether there are any diagnosis restrictions;

whether the location at which the medical procedure was performed is valid;

whether the medical procedure could have been performed at a cheaper location, and the difference in fees between the two locations;

whether the medical procedure involved a medical service provider with a medical specialty;

whether the medical claim must be reviewed manually;

whether required documentation such as X-rays are included;

whether the medical procedure was a medical emergency;

whether the location at which the medical procedure was performed is valid;

whether the medical procedure could have been performed at a cheaper location, and the difference in fees between the two locations;

whether the dates of the medical procedure occur between the effective date and the termination date of the medical plan;

whether the patient'"'"'s medical plan has a rider, and the terms of the rider;

whether there are any diagnosis restrictions;

whether there are any medical procedure restrictions;

the gender of the patient;

whether the medical procedure was performed by the patient'"'"'s primary care physician or a different or affiliated medical service provider;

whether the medical service provider is a preferred or non-preferred medical service provider under the medical plan;

whether the medical procedure is performed by a specialist;

whether the patient falls within any applicable age restrictions;

whether the medical claim requires manual review;

whether a standard fee or a modified fee is used, and the difference between these two types of fees;

whether required documentation is included;

whether the medical procedure is an emergency;

the dental area affected by the medical procedure;

whether the medical procedure involved a prosthesis; and

whether the medical procedure was pre-approved or pre-authorized.

22. The method of claim 12 wherein:

the method of adjudicating the medical claim is performed real-time.

23. The method of claim 12 wherein:

the method of adjudicating the medical claim is transaction-based.

24. A method of adjudicating a medical claim comprising:

providing a first plurality of requirements for a first claim;

providing a second plurality of requirements for a second claim wherein the second claim has a higher monetary value than the first claim;

electronically receiving the medical claim for a medical procedure;

setting a first score for the first claim to an initial value;

setting a second score for the second claim to the initial value;

electronically comparing a plurality of components of the medical claim to the first and second pluralities of requirements;

electronically changing the first score in a first direction for each one of the plurality of components that match one of the first plurality of requirements;

electronically changing the first score in a second direction for each one of the first plurality of requirements that is missing from the plurality of components;

electronically changing the second score in the first direction for each one of the plurality of components that match one of the second plurality of requirements;

electronically changing the second score in the second direction for each one of the second plurality of requirements that is missing from the plurality of components;

electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of the medical procedure for a medical service provider associated with the medical procedure; and

electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of medical coverage for a patient associated with the medical procedure,

wherein electronically selecting one of the first and second claims based upon predetermined criteria applied to their respective scores to determine a monetary value of medical coverage for a patient associated with the medical procedure further comprises;

if the first score was changed only in the first direction and if the second score was changed in the second direction, settling the medical claim as the first claim;

if the first score was changed in the second direction and if the second score was changed only in the first direction, settling the medical claim as the second claim;

if the first and second scores were changed only in the first direction and;

if the first score is further away in the first direction from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first direction from the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the second claim; and

if the first and second scores were changed in the second direction and;

if the first score is further away in the first direction from the initial value than the second score, settling the medical claim as the first claim;

if the second score is further away in the first direction from;

the initial value than the first score, settling the medical claim as the second claim; and

if the first and second scores are identical to each other, settling the medical claim as the second claim.