Healthcare financial data and clinical information processing system

• US 7,797,172 B2
• Filed: 09/24/2002
• Issued: 09/14/2010
• Est. Priority Date: 04/16/2002
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Siemens Medical Solutions USA Incorporated (Siemens AG)
• Inventors: Lucas, Brian, Klassen, David Hiebert Sr., Long, Greg, Fitzgerald, David, Hunter, John
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): RANGREJ, SHEETAL
• Application Number:
  US10/253,223
• Publication Number:
  US 20030195771A1
• Time in Patent Office: 2,912 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 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

A patient claim data processing system responds to and initiates clinical events and attains early accurate claim data during a patient healthcare encounter cycle to support prompt claim data validation and editing both for individual claim elements and for a completed claim to improve claim accuracy prior to claim submission to a payer. The system submits accurate claims to payers and receives remittance advice from payers and applies rules to the advice. A system processes financial data related to provision of healthcare to a patient in response to clinical events. The system includes an interface processor for receiving a message identifying an event and a related change in healthcare data concerning a patient and also includes a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient. A rules processor initiates application of a rule derived from the rules source to process financial data concerning provision of the individual service to the patient in response to receiving the message identifying the event. A result processor initiates an action in response to a result derived by the application of the rule to process the financial data. The rules processor also validates the financial data complies with the rule.

Claims

1. A system for processing claim data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

a source of rules for validating claim data elements concerning provision of individual services to a patient;

a rules processor for automatically initiating application of a plurality of rules derived from said rules source to identify claim data element deficiencies and automatically correcting claim data element deficiencies to make a claim for reimbursement valid for payment by a payer organization in response to receiving said messages identifying said clinical events; and

a result processor for automatically initiating performance of an action in response to a result derived by said application of said rules to individually validate different claim data elements.

2. A system according to claim 1, wherein

said plurality of rules are automatically selected from said rules source in response to an identified type of said clinical event.

3. A system, for processing financial data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving a message identifying a clinical event and a related change in healthcare data concerning a patient;

a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to process financial data concerning provision of a plurality of individual services to said patient to validate a claim for reimbursement for performance of said services is valid for payment by a payer organization in response to receiving said message identifying said clinical event; and

a result processor for automatically initiating performance of an action in response to a result derived by said application of said rule to process said financial data wherein

said action comprises automatic correction of claim data deficiencies to make said claim for reimbursement valid for payment by said payer organization and

said clinical event comprises at least one of, (a) generation of an indication of occurrence of provision of healthcare to a patient by an operating process, (b) generation of an indication of occurrence of provision of healthcare to a patient by patient monitoring equipment and (c) generation of an indication of occurrence of provision of healthcare to a patient by a medical device.

4. A system for processing financial data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving a message identifying a clinical event and a related change in healthcare data concerning a patient;

a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to process financial data concerning provision of a plurality of individual services to said patient to validate a claim for reimbursement for performance of said services is valid for payment by a payer organization in response to receiving said message identifying said clinical event; and

a result processor for automatically initiating performance of an action in response to a result derived by said application of said rule to process said financial data wherein said result processor, in response to said derived result, initiates addition of a task to a worklist of a healthcare worker, said task comprising review of data derived as said result of said application of said rule to process said financial data and

said result processor provides data prompting a user with a candidate alternative service and

said data for review comprises at least one of, (a) a notification of denial of a particular treatment for a patient, (b) a notification of a requirement for a waiver to be provided for qualification of a treatment for reimbursement and (c) a result of processing a trial claim for reimbursement for a particular treatment for a patient.

5. A system for processing financial data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving a message identifying a clinical event and a related change in healthcare data concerning a patient;

a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to process financial data concerning provision of a plurality of individual services to said patient to validate a claim for reimbursement for performance of said services is valid for payment by a payer organization in response to receiving said message identifying said clinical event; and

a result processor for automatically initiating performance of an action in response to a result derived by said application of said rule to process said financial data wherein said result processor, in response to said derived result, initiates addition of a task to a worklist of a healthcare worker, said task comprising review of data derived as said result of said application of said rule to process said financial data and wherein

said rules processor automatically initiates application of rules derived from said rules source to process data concerning provision of individual services to said patient by examining a billing record to determine if no payment has been made by a healthcare payer organization within a predetermined period in response to receiving said message identifying said clinical event, and

said result processor, in response to said derived result, automatically initiates actions to collect said overdue payment.

6. A system for processing financial data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving a message identifying a clinical event and a related change in healthcare data concerning a patient;

a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to process financial data concerning provision of a plurality of individual services to said patient to validate a claim for reimbursement for performance of said services is valid for payment by a payer organization in response to receiving said message identifying said clinical event; and

a result processor for automatically initiating performance of an action in response to a result derived by said application of said rule to process said financial data wherein said result processor, in response to said derived result, initiates addition of a task to a worklist of a healthcare worker, said task comprising review of data derived as said result of said application of said rule to process said financial data and wherein

said result processor, in response to said derived result, initiates addition of a task to a worklist for medical equipment.

7. A system for processing financial data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving a message identifying a clinical event and a related change in healthcare data concerning a patient;

a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to process financial data concerning provision of a plurality of individual services to said patient to validate a claim for reimbursement for performance of said services is valid for payment by a payer organization in response to receiving said message identifying said clinical event; and

a result processor for automatically initiating performance of an action in response to a result derived by said application of said rule to process said financial data wherein said result processor, in response to said derived result, initiates addition of a task to a worklist of a healthcare worker, said task comprising review of data derived as said result of said application of said rule to process said financial data and wherein

said result processor automatically initiates a search for records of services not billed for and

said characteristics associated with reimbursement to a provider for provision of an individual service to a patient, comprise at least one of, (a) an expected reimbursement amount for provision of an individual service to a patient, (b) an effective benefit period for said reimbursement, (c) contract constraints for said reimbursement, (d) an indication said provision of said individual service to said patient qualifies for reimbursement under a particular insurance plan and (e) an indication said provision of said individual service to said patient is linked to provision of other services to said patient.

8. A system for processing claim data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

a source of rules for validating claim data elements concerning provision of individual services to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to individually validate different claim data elements concerning provision of corresponding different individual services to a patient are valid for reimbursement for payment by a payer organization in response to receiving said messages identifying said clinical events; and

a result processor for automatically initiating performance of an action including initiating transfer of patient insurance and demographic data to a location accessible by a physician in response to a result derived by said application of said rules to individually validate different claim data elements wherein

said action comprises automatic correction of claim data deficiencies to make said claim for reimbursement valid for payment by said payer organization and

said rules processor collates validated claim data elements to produce a claim for provision of a plurality of services to said patient.

9. A system according to claim 8, wherein

said rules processor validates a plurality of claim data elements comply with reimbursement rules requiring combined reimbursement for provision of different services.

10. A system according to claim 8, wherein

said rules processor automatically initiates submission of said validated collated claim data elements to a payer, in response to successful validation.

11. A system for processing claim data related to patient healthcare in response to clinical events, comprising:

an interface processor for receiving messages identifying clinical events related to corresponding claim data elements concerning a patient;

a source of rules for validating claim data elements concerning provision of individual services to a patient;

a rules processor for automatically initiating application of a plurality of rules automatically selected from said rules source in response to an identified type of said clinical event to individually validate different claim data elements concerning provision of corresponding different individual services to a patient are valid for reimbursement for payment by a payer organization in response to receiving said messages identifying said clinical events; and

a result processor for automatically initiating performance of an action including initiating transfer of patient insurance and demographic data to a location accessible by a physician in response to a result derived by said application of said rules to individually validate different claim data elements wherein

said result processor prompts a user with a candidate alternative service in response to unsuccessful validation of a claim data element for provision of a particular service.