Automated system and method for health care administration

• US 7,698,153 B2
• Filed: 03/17/2006
• Issued: 04/13/2010
• Est. Priority Date: 12/13/1996
• Status: Expired due to Fees

• Current Assignee: Blue Cross And Blue Shield Of South Carolina
• Original Assignee: Blue Cross And Blue Shield Of South Carolina
• Inventors: Wiggins, Stephen K.
• Primary Examiner(s): Morgan; Robert W
• Assistant Examiner(s): BURGESS, JOSEPH D
• Application Number:
  US11/378,896
• Publication Number:
  US 20060212315A1
• Time in Patent Office: 1,488 Days
• Field of Search: 705/2, 705/3, 705/4, 705/35
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

An information collection and processing system and related automated method for use by an organization providing health care to a given population. The system includes an arrangement for storing information relating to a plurality of contractual relationships existing between the organization, a plurality of health care providers, and a plurality of payors. The storage arrangement also includes information relating to a plurality of patients in the given population, and information relating to transactions between the organization, providers and the payors. An aspect of the system and method relates to storing information relating to an expected receivable resulting from an encounter between a patient and one or more of the providers, storing information relating to a corresponding remittance received as a result of said encounter, comparing the expected receivables with the corresponding remittances, and initiating an action if the remittance falls outside of predetermined limits of the respective receivable.

Claims

1. An information collection and processing system for use by an organization providing managed and non-managed health care to a given population, wherein at least a portion of said population is covered by a negotiated agreement, comprising:

an information storage arrangement having;

a. a first portion for storing information relating to a plurality of contractual relationships existing between the organization, a plurality of providers of goods and/or services, and a plurality of payors;

b. a second portion for storing information relating to a plurality of patients in the given population;

c. a third portion for storing information relating to at least one of;

1. utilization management functions;

2. demand management functions;

3. catastrophic case management functions; and

4. chronic and preventive services management functions; and

d. a fourth portion for storing information relating to transactions between the organization, the providers and the payors;

a processor for reading and writing information from and to the storage arrangement, and for processing said information;

an input device and an output device for communicating information to and from the processor and the storage arrangement;

automated means for processing claims relating to transactions covered by said negotiated agreement; and

means for periodically generating projected receivables for transactions covered by said negotiated agreement, means for comparing respective payments received to the projected receivables, and means for initiating an action if a received payment does not fall within a predetermined percentage of a respective projected receivable.

2. An information collection and processing system according to claim 1, further comprising means for assigning unique identifiers to elements of information stored in the first portion of the storage arrangement, and for storing the unique identifiers in a data base.

3. An information collection and processing system according to claim 1, further comprising means for identifying said plurality of providers, payors or patients by any of a plurality of identifiers by which said providers, payors, or patients may be known.

4. An information collection and processing system according to claim 1, further comprising means for storing a summary of patient contacts with the organization and the providers in a data base, and for providing online access to the summary.

5. Apparatus for administering a health care system, comprising;

an information storage arrangement having;

a. a first portion for storing information relating to a plurality of contractual relationships existing between an a plurality of health care providers, and a plurality of payors;

b. a second portion for storing information relating to a plurality of patients in a given population, said information including a patient identifier and a record of encounters between an individual patient and one or more of the providers;

c. an input claims file for storing a plurality of claims from one or more of the providers;

d. a third portion for storing information relating to an expected receivable resulting from each respective encounter; and

e. a fourth portion for storing information relating to corresponding remittances received as a result of each encounter;

a processor for processing said received claims to determine which claims are to be submitted to which of one or more of the payors; and

an input device and an output device for communicating information to and from the processor and the storage arrangement;

wherein at least a portion of the population is covered by a negotiated agreement, and further comprising means for periodically generating projected receivables for transactions covered by said negotiated agreement, means for comparing respective payments to the projected receivables, and means for initiating an action if a respective payment does not fall within a predetermined percentage of a respective projected receivable.

6. In an information collection and processing system having a processor, an input arrangement, an output arrangement, and an information storage arrangement, an automated method for use by an alliance of organizations providing managed and non-managed health care to a given population, comprising the steps of:

a. storing information relating to a plurality of contractual relationships existing between the alliance, a plurality of providers of goods and/or services, and a plurality of payors;

b. storing information relating to a plurality of patients in the given population, said information including a patient identifier and a record of encounters between each patient and each provider;

c. storing information relating to transactions between the alliance, the providers and the payors;

d. storing a plurality of identifiers for each of the plurality of providers and payors;

e. processing said stored information to associate information relating to a particular patient with said patient'"'"'s identifier, and to associate information relating to a particular provider or payor with each stored identifier for that provider or payor;

f. receiving a plurality of claims from one or more of the providers and storing said claims in an input claims file;

g. processing said received claims to determine which claims are to be submitted to which of one or more of the payors;

h. submitting said claims to said one or more of the payors;

i. storing information relating to accounts receivables relating to said plurality of claims;

j. comparing, using the processor, remittances received from said one or more payors to amounts expected to be received for respective receivables;

k. initiating a first action if a remittance falls within predetermined limits of a respective receivable; and

l. initiating a second action if the remittance falls outside of predetermined limits of the respective receivable.

7. An automated method according to claim 6, further comprising the steps of assigning a unique identifier to elements of information relating to said contractual relationships, and storing the unique identifiers in a data base.

8. An automated method according to claim 6, further comprising the additional step of storing demographic information relating to the alliance, the providers, and the payors in a demographics data base.

9. An automated method according to claim 8, further comprising the additional step of generating an application package relating to certification or credentialing of a provider using information stored in the demographics data base.

10. An automated method according to claim 9, further comprising the additional steps of monitoring expiration dates of applicable certification or credentialing information, and automatically generating a request for updated information.

11. An automated method according to claim 6, comprising the additional step of storing information relating to capitation contracts in a capitation data base.

12. An automated method according to claim 6, comprising the additional step of storing rules relating to system utilization, billing and benefits in a rules data base.

13. An automated method according to claim 6, further comprising the additional steps of identifying, within the given population, subpopulations requiring health care information and/or reminders, and causing said information and/or reminders to be forwarded to patients to improve compliance with preventive and disease-specific protocols.

14. An information collection and processing system for use by an alliance of organizations providing managed and non-managed health care to a given population, comprising:

an information storage arrangement having;

a. a first portion for storing information relating to a plurality of contractual relationships existing between the alliance, a plurality of providers of goods and/or services and a plurality of payors;

b. a second portion for storing information relating to a plurality of patients in the given population;

c. a third portion for storing information relating to at least one of;

1. utilization management functions;

2. demand management functions;

3. catastrophic case management functions; and

4. chronic and preventive services management functions; and

d. a fourth portion for storing information relating to transactions between the alliance, the providers and the payors;

a processor for reading and writing information from and to the storage arrangement, and for processing said information;

an input device and an output device for communicating information to and from the processor and the storage arrangement;

means for receiving a plurality of claims from one or more of the providers and storing said claims in an input claims file;

means for processing said received claims to determine which claims are to be submitted to which of one or more of the payors;

means for submitting said claims to said one or more of the payors;

means for storing information relating to accounts receivables relating to said plurality of claims;

means for comparing remittances received from said one or more payors to amounts expected to be received for respective receivables;

means for initiating a first action if a remittance falls within a predetermined percentage of a respective receivable; and

means for initiating a second action if the remittance falls outside of the predetermined percentage of the respective receivable.

15. An information collection and processing system according to claim 14, further comprising means for assigning unique identifiers to elements of information stored in the first portion of the storage arrangement, and for storing the unique identifiers in a data base.

16. An information collection and processing system according to claim 14, further comprising means for identifying said plurality of providers, payors or patients by any of a plurality of identifiers by which said providers, payors, or patients may be known.

17. An information collection and processing system according to claim 14, further comprising means for storing a summary of patient contacts with the alliance and the providers in a data base, and for providing online access to the summary.

18. An information collection and processing system according to claim 14, further comprising means for identifying, within the given population, subpopulations requiring health care information and/or reminders, and causing said information and/or reminders to be forwarded to patients to improve compliance with preventive and disease specific protocols.