System and method for implementing healthcare fraud countermeasures

• US 7,421,398 B2
• Filed: 03/19/2007
• Issued: 09/02/2008
• Est. Priority Date: 01/22/2003
• Status: Expired due to Fees

• Current Assignee: Scott T. Kimmel
• Original Assignee: Scott T. Kimmel
• Inventors: Kimmel, Scott T.
• Primary Examiner(s): Gilligan; C. Luke
• Assistant Examiner(s): RINES, ROBERT D
• Application Number:
  US11/688,209
• Publication Number:
  US 20070260484A1
• Time in Patent Office: 533 Days
• Field of Search: 705/2, 705/3
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/06 Buying, selling or leasing transactions
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A method of discouraging healthcare fraud in conjunction with providing a health care service to a patient in which the patient provides a biometric signature. An event record is created where the event record creates an association between the biometric signature, a patient identifier, and location information indicating a location at which the biometric signature is obtained. The event record is stored in a central data store and can be later retrieved to verify the patient was present at the location.

Claims

1. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of a patient identifier, said biometric signature, and location information indicating said particular location at which said biometric signature is obtained and at which said health care service is provided and said event record indicates the absence of phantom billing, wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

2. The method of claim 1 further comprising making a reimbursement decision by said payer entity using said information related to said event record.

3. The method of claim 1 further comprising storing said event record in a computerized data store.

4. The method of claim 1 further comprising obtaining a biometric signature at least twice during said provision of health care services.

5. The method of claim 1 further comprising:

receiving a claim for reimbursement for said health care services;

retrieving one or more event records corresponding to said health care services from said data store;

matching said claim for reimbursement to an event record for a particular patient to determine whether said one or more event records indicate that said patient was at a suitable location for reimbursing said health care services; and

authorizing financial reimbursement of said health care service based in part upon said determination that said patient was present at a location suitable for reimbursing said health care service.

6. The method of claim 1 further comprising:

retrieving one or more records from said data store; and

performing a fraud detection process using said retrieved records.

7. The method of claim 1 wherein said biometric signature comprises a fingerprint record.

8. The method of claim 1 wherein said location information comprises an identification code assigned to a heath care facility.

9. The method of claim 1 wherein said location information comprises a network address of a computer used to obtain said biometric signature.

10. The method of claim 1 wherein said location information comprises a device address of a fingerprint scanner.

21. The method of claim 1 wherein said act of storing said event record is performed before said biometric signature is used to identity said patient receiving said healthcare services.

22. The method of claim 1 wherein said act of storing said event record is performed before said biometric signature is used to authenticate said person receiving said healthcare service.

11. A biometric audit trail system comprising:

means for causing a patient to provide a biometric signature on a date and at a location where the health care service is provided;

means for capturing said biometric signature;

means for creating a record that records said patient was at said location at a particular time and/or date, said record comprising a patient identifier, said biometric signature, location information indicating said particular location at which said biometric signature is obtained;

means for storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

means for providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

means for determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

means for indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

12. The system of claim 11 further comprising processes operable to analyze said retrieved biometric records to identify patterns amongst a plurality of biometric records.

13. The system of claim 11 wherein said biometric record further comprises a timestamp indicating a time and/or date at which said biometric information was obtained.

14. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of said biometric signature and location information indicating said particular location at which said biometric signature is obtained and at which said health care service is provided wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

15. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of said biometric signature and at least one timestamp indicating a time and/or date at which said biometric signature is obtained and at which said health care service is provided and said event record indicates the absence of phantom billing, wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

16. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of a patient identifier, said biometric signature, at least one timestamp, and location information indicating said particular location at which said biometric signature is obtained and at which said health care service is provided wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

17. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of a patient identifier, said biometric signature, at least two timestamps indicating a range of times at which said health care service was provided, and location information indicating said particular location at which said biometric signature is obtained and at which said health care service is provided and said event record indicates the absence of phantom billing, wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

18. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of a patient identifier, said biometric signature, metadata, and location information indicating said particular location at which said biometric signature is obtained and at which said health care service is provided and said event record indicates the absence of phantom billing, wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

19. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of said biometric signature, location information, and at least one timestamp indicating a time and/or date at which said biometric signature is obtained and at which said health care service is provided, wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.

20. A method of discouraging phantom billing healthcare fraud comprising:

providing a health care service;

in conjunction with providing said health care service at a particular location to a patient, causing said patient to provide a biometric signature;

capturing said biometric signature;

creating an event record that records said patient was at said particular location at a particular time and/or date, said event record consisting of said biometric signature, location information indicating a location at which said biometric signature is obtained and at which said health care service is provided, wherein said event record is created using a computer system;

storing said record in a computerized data store, wherein said record corresponds to reimbursement information and said location information in said record provides evidence that a particular patient was at a suitable location for providing said healthcare services;

providing an interface to said computerized data store wherein said interface receives said reimbursement information and determines whether a record in said computerized data store matches said reimbursement information;

determining whether said record corresponds to said reimbursement information wherein the absence of a positive match indicates a phantom bill;

indicating to a payer entity whether said particular patient was at a suitable location for providing said healthcare services based on said determination.