Method and apparatus for repricing a reimbursement claim against a contract

• US 7,904,317 B1
• Filed: 05/23/2000
• Issued: 03/08/2011
• Est. Priority Date: 10/14/1999
• Status: Expired due to Fees

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Lesswing, Mark, Hoerle, Dale
• Primary Examiner(s): Frenel; Vanel
• Application Number:
  US09/577,386
• Time in Patent Office: 3,941 Days
• Field of Search: 705 2- 4, 705 36- 37, 707/200
• US Class Current: 705/4
• 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 40/04 Trading; Exchange, e.g. stocks, commodities, derivatives or currency exchange
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method for repricing a reimbursement claim under at least one contract is provided herein. The method includes converting each contract into a series of contractual terms, where each contractual terms contains qualification codes, calculation codes and priority notes. The method than converts a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes. The method than begins to compare comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract and when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, the method identifies the contractual term as a matching contractual term associated to the claim line. Upon identifying all matching contractual terms, either to the claim line or the entire claim, the method will determine any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions. The method then calculates the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms. The method may then determine and make any adjustments depending upon any discount terms for the entire reimbursement amount.

Claims

1. A computer implemented method of repricing an electronically received reimbursement claim under at least one contract comprising:

providing programming code for converting each contract into a plurality of terms and a contract identifier code, each term, of the plurality of terms, containing qualification codes, calculation codes and at least two priority notes, and arranging the plurality of terms, of said contract, into a sequential series of terms;

providing programming code for converting the reimbursement claim into a series of claim lines, each claim line containing a claim code, a unit number and a corresponding charge;

providing programming code for sequentially comparing each claim code, of the series of claim lines, against each qualification code, of the plurality of terms and when a claim code, of a claim line, is substantially equal to a qualification code, of a term, identifying said term as a matching term associated to said claim line,

providing programming code for determining any priority conditions associated to all of the matching terms, and eliminating any matching terms that are excluded by said priority conditions; and

providing programming code for determining a reimbursement amount for the claim by processing the calculation codes of the non-eliminated matching terms.

2. The computer implemented method of claim 1 wherein the programming code for determining any priority conditions include:

programming code for categorizing the terms, of the sequential series of terms, into pre-defined sections, wherein the pre-defined sections have a hierarchy that lists a pre-defined section having priority over another pre-defined section prior to said other pre-defined section.

3. The computer implemented method of claim 2 wherein the programming code for determining any priority conditions further include:

programming code for arranging the terms, within each pre-defined section, by a reverse hierarchy, which sequential lists a term, having priority over another term, subsequent to said other term.

4. The computer implemented method of claim 3 wherein the step of sequentially comparing further includes:

when a claim code, of a claim line, is substantially equal to a qualification code of a term, programming code for identifying the pre-defined section in which the term is categorized under as a governing pre-defined section for said claim line;

programming code for sequentially comparing the claim code of said claim line, only against the qualification codes, of each term categorized under said governing pre-defined section; and

when the claim code of said claim line is substantially equal to a qualification code, of a term categorized under said governing pre-defined section, programming code for identifying said term as a matching term associated to said claim line.

5. The computer implemented method of claim 4 wherein the step of determining the reimbursement amount includes:

programming code for determining a reimbursement charge for each claim line associated to a non-eliminated matching term; and

programming code for adding the reimbursement charges for said claim lines, whereby the reimbursement amount for the claim is the addition of the reimbursement charges.

6. The computer implemented method of claim 5 wherein when a priority note, of a non-eliminated matching term, indicates that the calculation codes, of said non-eliminated matching term, apply to the entire claim, programming code for making the reimbursement amount for the claim equal to the reimbursement charge for the claim line associated to said non-eliminated matching term.

7. The computer implemented method of claim 6 wherein when a term, indicates that the calculation codes, of said term, apply to the reimburse amount of the claim, the method further including:

programming code for determining the reimbursement amount of said claim; and

when the qualifications of said term are satisfied, programming code for re-calculating the reimbursement amount based upon the calculation codes of said term.

8. The computer implemented method of claim 7 wherein the step of converting the claim further includes the step of programming code for associating the claim to a claim identifier code.

9. The computer implemented method of claim 8 further including:

programming code for comparing the claim identifier code, against the contract identifier code, of each contract, and when the claim identifier code is substantially equal to a contract identifier code, of a contract, identifying said contract as a governing contract, wherein the repricing of said claim is repriced only against said governing contract.

10. The computer implemented method of claim 9 wherein the step of repricing the claim against said governing contract further includes:

when at least two contracts are identified as governing contracts, programming code for repricing said claim against each governing contract creating a list of governing reimbursement amounts.

11. The computer implemented method of claim 10 further comprising:

programming code for determining a lowest governing reimbursement amount, of the list of governing reimbursement amounts, wherein the lowest governing reimbursement amount is the reimbursement amount of said claim.

12. An article of manufacture comprising:

a computer usable medium having computer readable program code embodied therein for repricing a reimbursement claim against at least one contract, said claim containing a claim identifier, a plurality of claim lines and a total charge, said contract containing a contract identifier and a plurality of contractual terms, the computer readable program code means in the article of manufacture comprising;

computer readable program code means for causing a computer to generate a rate sheet which represents a contract, of the at least one contract, the rate sheet containing one or more rate terms that represent the contractual terms of said contract, and containing a rate identifier code that represents the contract identifier of said contract;

computer readable program code means for causing a computer to generate the claim, the claim having a claim identifier codes and a series of claim lines, each claim line including a claim code, a unit number and a code charge;

computer readable program code means for causing a computer to reprice the claim against a rate sheet, and to generate and assign a reimbursement amount to said repriced claim; and

computer readable program code means for causing a computer to graphically display the reimbursement amount of the repriced claim, and a difference between the total charge of the claim and the reimbursement amount of the repriced claim.

13. The article of manufacture of claim 12, wherein the computer readable program code means for causing a computer to generate a rate sheet further includes:

computer readable program code means for causing a computer to assign qualification codes, calculation codes and at least one priority note to each rate term, and to arrange said rate terms into a sequential series of terms.

14. The article of manufacture of claim 13, wherein the computer readable program code means for causing a computer to generate a rate sheet further includes:

computer readable program code means for causing a computer to graphically convey the rate sheet by displaying the sequential series of terms in an English language representation.

15. The article of manufacture of claim 14, wherein the computer readable program code means for causing a computer to generate a rate sheet further includes:

computer readable program code means to generate and display each rate term as a English language paragraph with a series of data entry panels interspersed in the paragraph, the data entry panels prompting a user to define the calculation codes, qualification codes and priority codes for each rate term.

16. The article of manufacture of claim 15, wherein the computer readable program code means for repricing the claim against a rate sheet further includes:

computer readable program code means causing a computer to sequentially compare each claim code, included in the series of claim lines, against each qualification code, of each rate term; and

when a claim code, of a claim line, is substantially equal to a qualification code, of a rate term, the computer readable program code means causing a computer to identify said rate term as a matching rate term associated to said claim line;

computer readable program code means causing a computer to determine any priority conditions associated to the matching rate terms and to eliminate any matching rate terms that are excluded by said priority conditions defining a series of remaining matching rate terms; and

computer readable program code means causing a computer to compute the reimbursement amount from the calculation codes of the remaining matching rate terms.

17. The article of manufacture of claim 16, wherein the computer readable program code means for causing a computer to generate a rate sheet further includes:

computer readable program code means to categorize the rate terms, of the rate sheet, in pre-defined sections, the pre-defined sections have a hierarchy sequence that assigns priority conditions to the rate terms categorized therein.

18. The article of manufacture of claim 17, wherein the article of manufacture further includes:

computer readable program code means causing a computer to assign priority conditions to the priority codes of the rate terms categorized within one of the predefined sections, said priority conditions defining a priority sequence of said rate terms.

19. The article of manufacture of claim 18, wherein the computer readable program code means for causing a computer to sequentially compare each claim code further includes:

when a claim code, of a claim line, is substantially equal to a qualification code, of a rate term, the computer readable program code means causing a computer to identify the pre-defined section in which the rate term is categorized under as a governing pre-defined section for said claim line;

computer readable program code means causing a computer to sequentially compare the claim code of said claim line, against only the qualification codes, of each rate term categorized under said governing pre-defined section; and

when the claim code of said claim line is substantially equal to a qualification code, of a term categorized under said governing pre-defined section, the computer readable program code means causing a computer to identify said term as a matching term associated to said claim line.

20. The article of manufacture of claim 19, wherein the article of manufacture further includes:

computer readable program code means causing a computer to compare the claim identifier against the rate identifier code and to identify a rate sheet as a governing rate sheet which has a rate identifier code substantially equal to the claim identifier; and

computer readable program code means causing a computer to reprice the claim only against a governing rate sheet.

21. The article of manufacture of claim 20, wherein the article of manufacture further includes:

when at least two rate sheets are identified as governing rate sheets, computer readable program code means causing a computer to reprice the claim against each governing rate sheet and to create a list of governing reimbursement amounts.

22. The article of manufacture of claim 21, wherein the article of manufacture further includes:

computer readable program code means causing a computer to receive an input from an user to direct the computer to assign either the highest or lowest governing reimbursement amount, from the list of governing reimbursement amounts, as the reimbursement amount of the repriced claim.

23. The article of manufacture of claim 22, wherein the article of manufacture further includes:

computer readable program code means for causing a computer to store in a repriced claim storage location a repriced claim along with the reimbursement amount of said repriced claim, said

repriced claim includes the claim identifier code and claim lines associated to said repriced claim.

24. The article of manufacture of claim 23, wherein the article of manufacture further includes:

computer readable program code means for causing a computer to compare the claim identifier code, of a claim, against the claim identifier code, of each repriced claim, stored in the repriced claim storage location;

when the claim identifier code, of said claim, is substantially equal to the claim identifier code, of a repriced claim, the computer readable program code means causing a computer to combine the claim lines of said claim with the claim lines of said repriced claim to create a bundled claim; and

computer readable program code means for causing a computer to reprice the bundled claim and rewrite said repriced claim with the repriced bundled claim.

25. The article of manufacture of claim 24, wherein the article of manufacture further includes:

computer readable program code means causing a computer to store in a rate sheet storage location the calculation codes, qualification codes and priority codes of a rate sheet.

26. The article of manufacture of claim 25, wherein the article of manufacture further includes:

computer readable program code means causing a computer to store in a claim storage location the claim lines of a claim.

27. The article of manufacture of claim 26, wherein the article of manufacture further includes:

computer readable program code means causing a computer to store in an identifier storage location a plurality of identifier codes substantially equal to the rate identifier codes, of each rate sheet, and the claim identifier codes, of each claim; and

computer readable program code means causing a computer to logically link each claim having a claim identifier code and each rate sheet having a rate identifier code that are substantially equal to a single identifier code, of the plurality of identifier codes; and

computer readable program code means causing a computer to receive inputs from a user, said inputs to cause the computer to access the identifier storage location and to change an identifier code, of the plurality of identifier codes, whereby each claim and each rate sheet logically linked to said identifier code is automatically changed.

28. A computer implemented method for repricing a reimbursement claim under at least one contract, (1) each claim containing at least one claim line, each claim line being defined by claim codes, a unit number and a corresponding charge, and (2) each contract containing at least one contractual term, each contractual term being defined by qualification codes, calculation codes, the method for repricing comprising:

comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract;

when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, identifying said contractual term as a matching contractual term associated to said claim line, and creating a list of all matching contractual terms;

determining any priority conditions associated to the matching contractual terms, and eliminating any matching contractual terms, from said list of matching terms that are excluded by said priority conditions; and

determining a reimbursement charge for each claim line associated to a non-eliminated matching term, and adding the reimbursement charges for said claim lines, wherein the reimbursement amount for the claim is the addition of said reimbursement charges.

29. The computer implemented method of claim 28 further comprising;

storing each contract on a network contract storage location, the network storage location containing a plurality of contract sets, each contract set associated to a set identifier, each contract further including a contract identifier and a set identifier, wherein each contract containing a set identifier substantially equal to a set identifier of a contract set, is stored within said contract set;

identifying each claim with a set identifier and a claim identifier;

comparing the set identifier of a claim against the set identifier, of each contract set, when the set identifier of a claim is substantially equal to the set identifier of a contract set, identifying said contract set as a governing contract set;

comparing the claim identifier of said claim against the contract identifiers of each contract, stored within said governing contract set, and when the claim identifier of said claim is substantially equal to the contract identifier of a contract, stored within said governing contract set, identifying said contract as a governing contract; and

determining the reimbursement amount of said claim only against said governing contract.

30. The computer implemented method of claim 29 wherein the priority conditions further includes:

categorizing the contractual terms, of each contract, into a set of sequentially listed predefined sections, wherein the pre-defined sections have a hierarchy that lists a pre-defined section, having priority over other pre-defined sections, before said other pre-defined sections.

31. The computer implemented method of claim 30 wherein the priority conditions further includes:

arranging the contractual terms, categorized in each pre-defined section, in a reverse hierarchy, wherein a contractual term having priority over other contractual terms is listed subsequent said other contractual terms.

32. The computer implemented method of claim 31, wherein the computer readable program code means for causing a computer to sequentially compare each claim code further includes:

when a claim code, of a claim line, is substantially equal to a qualification code, of a contractual term, the computer readable program code means causing a computer to identify the pre-defined section in which the contractual term is categorized under as a governing pre-defined section for said claim line;

computer readable program code means causing a computer to sequentially compare the claim code of said claim line, against only the qualification codes, of each contractual term categorized under said governing pre-defined section; and

when the claim code of said claim line is substantially equal to a qualification code, of a term categorized under said governing pre-defined section, the computer readable program code means causing a computer to identify said contractual term as a matching contractual term associated to said claim line.

33. The computer implemented method of claim 32 wherein the priority conditions include a claim priority condition which eliminates any matching contractual terms that is listed in a pre-defined section that is excluded by the claim priority condition.

34. The computer implemented method of claim 33 wherein when one of the priority notes associated to a matching contractual term indicates that said matching contractual term reprices the entire claim;

eliminating all other matching contractual terms.

35. The computer implemented method of claim 34 wherein the reverse hierarchy is determined by the priority notes associated to each contractual term, categorized in a pre-defined section.

36. The computer implemented method of claim 35 wherein the step of repricing further includes:

comparing the claim identifier code against the contract identifier code, of each contract, wherein when the claim identifier code is substantially equal to a contract identifier code, of a contract, identifying said contract as a governing contract; and

determining a reimbursement amount of the claim only against the governing contract.

37. The computer implemented method of claim 36 wherein the step determining a reimbursement amount for the claim against the governing contract includes:

when at least two contracts are identified as governing contracts, repricing said claim against each governing contract creating a list of governing reimbursement amounts, wherein the reimbursement amount of said claim is the lowest governing reimbursement amount.

38. The computer implemented method of claim 37 further including:

storing the reimbursement amount of a claim and storing said claim as a repriced claim.

39. The computer implemented method of claim 38 wherein prior to determining the reimbursement amount for a claim the method including:

comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;

when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, combining the claim lines of said claim with the claim line of said repriced claim creating a bundled claim;

determining the reimbursement amount of the bundled claim, instead of determining the reimbursement amount of said claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.

40. The computer implemented method of claim 28 further comprising:

tracking the priority conditions associated to the non-eliminated matching terms; and

displaying said priority conditions along with the reimbursement charge of the claim lines associated with said non-eliminated matching terms.

41. An article of manufacture comprising:

a computer usable medium having computer readable program code embodied therein for configuring a contract, containing contractual terms, for repricing a reimbursement claim, the computer readable program code means in the article of manufacture comprising;

computer readable program code means for causing a computer to generate a rate sheet representing the contractual terms of said contract, the rate sheet containing identifier codes, and one or more rate terms;

computer readable program code means for causing a computer to arrange the rate terms in a sequential series of terms; and

computer readable program code means for graphically conveying the rate sheet by displaying the sequential series of terms in an English language representation.

42. The article of manufacture of claim 41, wherein the article of manufacture further includes:

computer readable program code means to generate and display each rate term as a English language paragraph with a series of data entry panels interspersed in the paragraph, the data entry panels prompting a user to define calculation codes, qualification codes and priority codes for each rate term.

43. The article of manufacture of claim 42, where the article of manufacture further includes:

computer readable program code means to categorize the rate terms, of the rate sheet, in pre-defined sections, wherein the pre-defined sections have a pre-defined hierarchy sequence that assigns a priority to the rate terms categorized therein when repricing a claim.

44. The article of manufacture of claim 43, wherein the English language paragraph describes the qualification and calculation of the rate term when repricing a medical reimbursement claim.

45. The article of manufacture of claim 44, wherein the priority codes define a priority sequence to the rate terms within a pre-defined section, of said pre-defined sections.

46. The article of manufacture of claim 45, wherein the article of manufacture further includes:

computer readable program code means to permit a user to edit the calculation codes, qualification codes and priority codes of a rate term of the rate sheet.

47. The article of manufacture of claim 46, wherein the article of manufacture further includes:

computer readable program code means to store a rate sheet, in a data center containing a plurality of networks, each network containing a plurality of rate sheets, similarly configured; and

when the identifier codes of a rate sheet identifier a specific network, of the plurality of networks, the computer readable program code means stores said rate sheet in the specific network.