System and method for electronic remittance notice analysis

• US 7,725,335 B1
• Filed: 02/20/2004
• Issued: 05/25/2010
• Est. Priority Date: 02/20/2003
• Status: Expired

• Current Assignee: Waystar Technologies Incorporated
• Original Assignee: RemitData Incorporated (Waystar, Inc.)
• Inventors: Goodwin, Bently C.
• Primary Examiner(s): O'Connor; Jerry
• Assistant Examiner(s): Pauls; John A
• Application Number:
  US10/783,324
• Time in Patent Office: 2,286 Days
• Field of Search: 705/2, 705/4
• US Class Current: 705/4
• 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

Abstract

A system and method for analyzing electronic remittance notices (ERNs) is provided. The system includes a database component and a processor component for determining benchmark, for both denial rates and/or days sales outstanding, weighted average values for a particular provider and weighted average aggregate values based on a plurality of providers ERN claim adjudication information. The ERN information may originate from one or more third-party payers for claims for medical products or procedures. The weighting of these values may mimic or approximate a particular healthcare provider'"'"'s mix of medical products and/or services to provide much more meaningful information. This benchmark values may be compared to various other ERN metrics of ERN claim adjudication information to compare to aggregate healthcare provider information. Equalizer values may also be calculated, analyzed and compared.

Claims

1. An electronic remittance notice analysis system, comprising:

a database component operable to maintain electronic remittance notice information for a plurality of healthcare providers, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of the plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes information for each of the plurality of claims that includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and financial information; and

a processor component operable to access the database component and determine, for a period of time and for a plurality of claims, an average denial rate for each of the plurality of procedures for one of the plurality of healthcare providers, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the financial information, the processor further operable to determine a weighted average denial rate for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and a weighted average aggregate denial rate for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, the processor component is further operable to compare the weighted average denial rate and the weighted average aggregate denial rate, and the processor component is further operable to determine a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer.

2. The electronic remittance notice analysis system of claim 1, wherein the financial information includes an amount billed for a procedure.

3. The electronic remittance notice analysis system of claim 1, wherein the financial information includes an amount allowed for a procedure.

4. The electronic remittance notice analysis system of claim 1, wherein the financial information includes an amount paid for a procedure.

5. The electronic remittance notice analysis system of claim 1, wherein the financial information includes an average days sales outstanding for a procedure.

6. The electronic remittance notice analysis system of claim 1, wherein the electronic remittance notice information is generated by one or more third party payers.

7. The electronic remittance notice analysis system of claim 1, wherein the processor component is further operable to access the database component and determine, for a period of time and for a plurality of claims, an average days sales outstanding for each of the plurality of procedures for one of the plurality of healthcare providers, an average aggregate days sales outstanding for each of the plurality of procedures for the plurality of healthcare providers, a days sales outstanding weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the financial information, the processor further operable to determine a weighted average days sales outstanding for the period of time for the one of the plurality of healthcare providers based on the days sales outstanding weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and a weighted average aggregate days sales outstanding for the period of time for the plurality of healthcare providers based on the days sales outstanding weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, the processor component is further operable to compare the days sales outstanding and the weighted average aggregate days sales outstanding, and the processor component is further operable to determine a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer.

8. The electronic remittance notice analysis system of claim 7, wherein the financial information includes an amount billed for a procedure.

9. The electronic remittance notice analysis system of claim 7, wherein the financial information includes an amount allowed for a procedure.

10. The electronic remittance notice analysis system of claim 7, wherein the financial information includes an amount paid for a procedure.

11. The electronic remittance notice analysis system of claim 7, wherein the financial information includes an average denial rate for a procedure.

12. The electronic remittance notice analysis system of claim 7, wherein the electronic remittance notice information is generated by a third party payer.

13. The electronic remittance notice analysis system of claim 7, wherein the processor component is further operable to determine a composite equalizer based on an average of the denial rate equalizer and the days sales outstanding equalizer.

14. The electronic remittance notice analysis system of claim 13, wherein the average of the denial rate equalizer and the days sales outstanding equalizer is a weighted average.

15. An electronic remittance notice analysis system, comprising:

a database component operable to maintain electronic remittance notice information for a plurality of healthcare providers, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of the plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes information for each of the plurality of claims that includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and payment information; and

a processor component operable to access the database component and determine, for a period of time and for a plurality of claims, an average days sales outstanding for each of the plurality of procedures for one of the plurality of healthcare providers, an average aggregate days sales outstanding for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the payment information, the processor is further operable to determine a weighted average days sales outstanding for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and a weighted average aggregate days sales outstanding for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and the processor component is further operable to determine a percentage difference between the weighted average days sales outstanding and the weighted average aggregate days sales outstanding to generate a days sales outstanding equalizer.

16. The electronic remittance notice analysis system of claim 15, wherein the payment information includes an amount billed for a procedure.

17. The electronic remittance notice analysis system of claim 15, wherein the payment information includes an amount allowed for a procedure.

18. The electronic remittance notice analysis system of claim 15, wherein the payment information includes an amount paid for a procedure.

19. The electronic remittance notice analysis system of claim 15, wherein the payment information includes an average denial rate for a procedure.

20. A computerized method for analyzing electronic remittance notice information, comprising:

receiving electronic remittance notice information from a third party payer in a computer database, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of a plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and financial information;

determining, for a period of time and for the plurality of claims for each of the plurality of procedures, an average denial rate for each of the plurality of procedures for one of the plurality of healthcare providers;

determining, for the period of time and based upon at least part of the plurality of claims, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers;

determining a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the financial information;

determining a weighted average denial rate for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers; and

determining a weighted average aggregate denial rate for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers;

comparing the weighted average denial rate and the weighted average aggregate denial rate;

determining a percentage difference between the weighted average denial rate and the weighted average denial rate to generate a denial rate equalizer; and

outputting reports of custom benchmark information generated by the method.

21. The method of claim 20, wherein the electronic remittance notice information is generated by one or more third party payers.

22. The method of claim 20, further comprising:

determining, for the period of time and for the plurality of claims, an average days sales outstanding for each of the plurality of procedures for one of the plurality of healthcare providers;

determining, for the period of time and based upon at least part of the plurality of claims, an average aggregate days sales outstanding for each of the plurality of procedures for the plurality of healthcare providers;

determining a weighted average days sales outstanding for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers; and

determining a weighted average aggregate days sales outstanding for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers.

23. The method of claim 22, further comprising:

determining a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer; and

determining a percentage difference between the weighted average days sales outstanding and the weighted average aggregate days sales outstanding to generate a days sales outstanding equalizer.

24. The method of claim 23, further comprising:

determining a composite equalizer based on an average of the denial rate equalizer and the days sales outstanding equalizer for analyzing the claim adjudication information.

25. The method of claim 20, further comprising:

receiving the electronic remittance notice information from the system of the one of the plurality of healthcare providers; and

communicating at least a portion of the electronic remittance notice information to the analysis system.

26. The method of claim 25, wherein the communication of the at least a portion of the electronic remittance notice information further includes:

providing an agent on the one of the plurality of healthcare provider systems to initiate transmission to the analysis system.