Correcting and monitoring status of health care claims

• US 7,739,132 B2
• Filed: 10/17/2003
• Issued: 06/15/2010
• Est. Priority Date: 10/17/2002
• Status: Active Grant

• Current Assignee: Waystar Technologies Incorporated (Waystar Holding Corp.)
• Original Assignee: Navicure (Waystar, Inc.)
• Inventors: Denny, James McCahill Jr., Edwards, Shawn Kevin, Bridge, Thomas Craig, Bradley, Kenneth Paul
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): Raj; Rajiv J
• Application Number:
  US10/688,363
• Publication Number:
  US 20040133452A1
• Time in Patent Office: 2,433 Days
• Field of Search: 705 2- 4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

The system is an advanced, web-enabled, clearinghouse that facilitates efficient and effective claim routing, monitoring and report retrieval. A claim status summary is displayed that links directly to a rejected claim listing, wherein each rejected claim listed is a link to associated detailed claim information. The detailed claim information display has fields to edit the associated detailed claim information. During the editing process, a rules verification is performed against the edited claim information to ensure the edit comply with the known rules for the associated payer. Upon successfully completing the rules verification, the edited claim is submitted to a payer.

Claims

1. In a medical insurance payment system having a plurality of medical providers and a plurality of insurance payers, wherein medical reimbursement claims are submitted electronically from practice management computer systems of the plurality of medical providers to claims processing computer systems of the plurality of insurance payers for payment determinations, wherein an intermediary claim management system is in electronic communication between the practice management computer systems of the plurality of medical providers and the claims processing computer systems of the plurality of insurance payers, wherein the intermediary claim management system includes a claim management database for storing claim information and a processor for performing a computer-implementable method for improving medical reimbursement claim processing between medical providers and insurance providers, comprising the steps of:

(a) prior to receiving a particular medical reimbursement claim at the intermediary claim management system from a particular medical provider;

(i) receiving a plurality of medical reimbursement claims at the intermediary claim management system electronically from the practice management computer systems of the plurality of medical providers, each of the plurality of claims including data about a patient of a respective provider, a service provided to the patient by the respective provider, and a respective payer to whom the claim must be submitted for payment;

(ii) submitting each of the plurality of claims electronically from the intermediary claim management system to the claims processing computer system of each respective payer for payment determination;

(iii) receiving a substantive response at the intermediary claim management system from the claims processing computer system of each respective payer for each respective claim, each substantive response including one or more of claim acknowledgement data, claim acceptance data, and claim rejection data, the claim rejection data including one or more payer claim rejection identifiers relating to specific issues in the claim identified by the respective payer;

(iv) for each substantive response that includes claim rejection data, associating via the intermediary claim management system processor each payer claim rejection identifier with one of a plurality of predefined claim rejection categories and one of a plurality of predefined rejection descriptions in the claim management database as a function of claim rejection identifier type;

(b) receiving the particular medical reimbursement claim at the intermediary claim management system electronically from the practice management computer system of the particular medical provider;

(i) generating a claim record for the particular claim via the intermediary claim management system processor, and storing the claim record in the claim management database;

(ii) submitting the particular claim electronically from the intermediary claim management system to the claims processing computer system of a particular insurance payer for payment determination;

(iii) receiving a particular substantive response at the intermediary claim management system from the claims processing computer system of the particular insurance payer for the particular claim;

(iv) if the particular substantive response includes claim rejection data, extracting one or more payer claim rejection identifiers from the claim rejection data via the intermediary claim management system processor;

(iv) determining a corresponding predefined claim rejection category and predefined rejection description for each extracted claim rejection identifier for the particular claim based on the predefined claim rejection category and predefined rejection description associated with the extracted claim rejection identifier in the claim management database;

(v) updating the claim record for the particular claim in the claim management database to include the corresponding predefined claim rejection category and predefined rejection description determined for each extracted claim rejection identifier; and

(vi) displaying each corresponding predefined claim rejection category and predefined rejection description for the particular claim to the particular medical provider based on the updated claim record for the particular claim,

whereby the particular medical provider is able to determine if further action on the particular claim is necessary as a function of specific issues associated with the particular claim.

2. The method of claim 1, wherein at least one of the specific issues in the plurality of claims identified by the plurality of insurance payers comprises required information missing from one or more of the claims.

3. The method of claim 1, wherein at least one of the specific issues in the plurality of claims identified by the plurality of insurance payers comprises information within a respective claim being internally discrepant.

4. The method of claim 3, wherein information within the respective claim is internally discrepant if at least two pieces of information are not permitted to coexist within the claim based on a rule of one or more of the plurality of insurance payers.

5. The method of claim 1, further comprising the step of, before submitting the particular medical reimbursement claim electronically from the intermediary claim management system to the claims processing computer system of the particular insurance payer for payment determination, determining if the particular claim has any potential specific issues based on rules within the intermediary claim management system derived from previous issues associated with the plurality of prior-received medical reimbursement claims, and if the particular claim has one or more specific issues, presenting the particular claim back to the particular medical provider for correction.

6. The method of claim 5, wherein the step of presenting the particular claim back to the particular medical provider comprises flagging the one or more specific issues in the claim that need to be corrected.

7. The method of claim 5, wherein the step of presenting the particular claim back to the particular medical provider comprises sending an email notification to the particular medical provider.

8. The method of claim 5, wherein the step of presenting the particular claim back to the particular medical provider comprises displaying one or more of the plurality of predefined claim rejection categories and one or more of the plurality of predefined rejection descriptions associated with the one or more specific issues in conjunction with the particular claim to the particular medical provider on an interactive, web-accessible site generated and provided by the intermediary claim management system.

9. The method of claim 8, further comprising the step of receiving edits to the particular claim from the respective provider directly within the interactive, web-accessible site, and updating the claim record for the particular claim to include the edits.

10. The method of claim 1, wherein each of the plurality of predefined rejection descriptions is displayed in a human-understandable text format.

11. The method of claim 1, further comprising the step of displaying a status of the particular claim to the particular medical provider prior to receiving the particular substantive response from the claims processing computer system of the particular insurance payer.

12. The method of claim 1, wherein each corresponding predefined claim rejection category and redefined rejection description for the particular claim is displayed to the particular medical provider on an interactive, web-accessible site generated by the intermediary claim management system.

13. The method of claim 1, wherein the step of displaying each corresponding predefined claim rejection category and predefined rejection description for the particular claim to the particular medical provider comprises sending an email notification to the particular medical provider.

14. The method of claim 1, further comprising the step of displaying a report about the particular claim to the respective particular medical provider on an interactive, web-accessible site generated and provided by the intermediary claim management system.

15. The method of claim 1, wherein at least one of the specific issues in the plurality of claims identified by the plurality of insurance payers comprises inaccurate information in one or more of the claims.

16. The method of claim 1, wherein the plurality of predefined claim rejection categories are selected from the group comprising:

eligibility errors, duplicate claim errors, provider enrollment errors, coding errors, patient demographic errors, payer information errors.

17. The method of claim 1, wherein one or more of the payer claim rejection identifiers are proprietary to each respective insurance payer.

18. The method of claim 1, wherein the claim acknowledgement data comprises information indicating that the respective claim has been accepted for processing by the respective payer.

19. The method of claim 1, wherein the claim acceptance data comprises information indicating the respective claim has been approved for payment by the respective payer and indicating terms of the payment.

20. The method of claim 19, wherein the claim acceptance data further comprises remittance advice.

21. The method of claim 1, wherein the step of associating each payer claim rejection identifier with one of the plurality of predefined claim rejection categories and one of the plurality of predefined rejection descriptions comprises linking each payer claim rejection identifier with one of the plurality of predefined claim rejection categories and one of the plurality of predefined rejection descriptions in a cross-referenced data structure in the claim management database.

22. The method of claim 1, wherein the step of determining the corresponding predefined claim rejection category and predefined rejection description for each extracted claim rejection identifier for the particular claim comprises:

comparing each extracted claim rejection identifier to previously-received claim rejection identifiers stored in the claim management database;

identifying a matching previously-received claim rejection identifier for each extracted claim rejection identifier; and

retrieving the associated predefined claim rejection category and predefined rejection description associated with each matched previously-received claim rejection identifier.

23. In a medical insurance payment system having a plurality of medical providers and a plurality of insurance payers, wherein medical reimbursement claims are submitted electronically from practice management computer systems of the plurality of medical providers to claims processing computer systems of the plurality of insurance payers for payment determinations, wherein an intermediary claim management system is in electronic communication between the practice management computer systems of the plurality of medical providers and the claims processing computer systems of the plurality of insurance payers, wherein the intermediary claim management system includes a claim management database for storing claim information and a processor for performing a computer-implementable method for improving medical reimbursement claim processing between medical providers and insurance providers, comprising the steps of:

(a) prior to receiving a particular medical reimbursement claim at the intermediary claim management system from a particular medical provider;

(i) receiving a plurality of medical reimbursement claims at the intermediary claim management system electronically from the practice management computer systems of the plurality of medical providers, each of the plurality of claims including data about a patient of a respective provider, a service provided to the patient by the respective provider, and a respective payer to whom the claim must be submitted for payment;

(ii) submitting each of the plurality of claims electronically from the intermediary claim management system to the claims processing computer system of each respective payer for payment determination;

(iii) receiving a substantive response at the intermediary claim management system from the claims processing computer system of each respective payer for each respective claim;

(iv) for each substantive response received from each respective payer, generating via the-intermediary claim management system processor claim history data indicative of (a) a response type, and (b) a response time, wherein the response time comprises the amount of time between submission of the respective claim to the respective payer and receipt of the substantive response from the respective payer;

(v) storing the claim history data in the claim management database;

(vi) for each respective payer, identifying one or more patterns in the claim history data indicating expected response types and expected response times for claims submitted to the respective payer;

(vii) generating a profile for each respective payer via the intermediary claim management system processor based on the one or more identified patterns in the claim history data, and storing each profile in the claim management database;

(b) receiving the particular medical reimbursement claim at the intermediary claim management system electronically from the practice management computer system of the particular medical provider, the particular claim including data identifying a particular insurance payer for payment of the particular claim;

(i) determining the particular insurance payer associated with the particular claim by extracting the data identifying the particular insurance payer from the particular claim via the intermediary claim management system processor;

(ii) retrieving a particular profile for the particular insurance payer from the claim management database;

(iii) extracting at least one expected response type and at least one expected response time from the particular profile for the particular payer based on the particular claim via the intermediary claim management system processor; and

(iv) displaying the at least once expected response type and the at least one expected response time for the particular claim to the particular medical provider,

whereby the particular medical provider is able to determine if further action on the particular claim is necessary based on the at least one expected response type and the at least one expected response time associated with the particular claim.

24. The method of claim 23, further comprising the steps of:

submitting the particular claim electronically from the intermediary claim management system to the claims processing computer system of the particular insurance payer for payment determination; and

generating and presenting an alert to the particular medical provider via the intermediary claims management system processor if a particular substantive response for the particular claim is not received by the intermediary claim management system within the at least one expected response time identified for the particular insurance payer.

25. The method of claim 23, wherein the response type is selected from the group comprising:

a rejection of the respective claim, a current status of the respective, claim, a request for additional information associated with the respective claim, an approval of the respective claim for payment.

26. The method of claim 23, wherein each substantive response comprises a report generated by each respective payer.