System for processing healthcare claim data

• US 7,917,378 B2
• Filed: 09/20/2002
• Issued: 03/29/2011
• Est. Priority Date: 04/09/2002
• 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, Zimmerman, Jon, Hunter, John
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): RANGREJ, SHEETAL
• Application Number:
  US10/247,980
• Publication Number:
  US 20030191665A1
• Time in Patent Office: 3,112 Days
• Field of Search: 705/3, 705/4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems

Abstract

A claim pre-processing system employs trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. A system processes claim data related to provision of healthcare to a patient The system includes a claim data collator for collating data related to a claim for a particular patient for submission to a payer and a source of rules for use in processing collated claim data. A pre-processor submits the collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment. A claim processor submits the collated claim data to a payer, in response to successful validation by the pre-processor. A rules processor processes acquired claim data to identify a condition triggering application of a different set of rules for determining validity of an individual claim element. The pre-processor re-submits amended collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment, the amended collated claim data being received in response to unsuccessful validation using the rules.

Claims

1. A system for processing claim data related to provision of healthcare to a patient, comprising:

a claim data collator for collating data related to a claim for a particular patient for submission to a payer;

a source of rules for use in processing collated claim data;

a pre-processor for submitting said collated claim data for automatic trial adjudication by a healthcare provider to determine expected adjudication results including expected reimbursement prior to submission for adjudication by a payer using said rules to validate said collated claim data is in condition for processing to initiate generation of payment;

a claim processor, for submitting said collated claim data to said payer for adjudication by said payer, in response to successful validation by said pre-processor; and

a rule creation processor for automatically creating said rules for use in processing collated claim data in response to previously identified claim data deficiencies wherein

said pre-processor re-submits amended collated claim data for processing using said rules to validate said collated claim data is in condition for processing to initiate generation of payment, said amended collated claim data being received in response to unsuccessful validation using said rules.

2. A system according to claim 1, wherein

a rule comprises a procedure for determining claim elements comply with predetermined requirements including at least one of, (a) health plan reimbursement conditions, (b) health plan claim format requirements, (c) a reimbursement formula, (d) reimbursement constraints and (e) reimbursement computation procedure.

3. A system according to claim 2, wherein

said claim elements comprise at least one of, (i) a portion of a claim, (ii) a complete claim, (iii) individual records of a claim and (iv) record data associated with an individual patient encounter with a healthcare service provider.

4. A system according to claim 1, wherein

a rule at least one of, (a) detects inconsistency between a plurality of data fields of said collated claim data and (b) determines whether an element of said collated claim data exceeds a payer designated limit.

5. A system according to claim 4, wherein

said plurality of data fields includes two or more of, (i) telephone number, (ii) zip code, (iii) address, (iv) another geographical identifier, (vi) clinical data and (vii) other claim data.

6. A system according to claim 1, wherein

said pre-processor automatically queues amended collated claim data for re-validation by said pre-processor.

7. A system according to claim 1, wherein

said pre-processor initiates generation of an alert message to a user to indicate a deficiency in said collated claim data likely to result in claim denial, in response to unsuccessful validation by said pre-processor, said deficiency being identified as a result of said validation.

8. A system according to claim 1, wherein

said pre-processor initiates scheduling of a task to be performed by a healthcare worker in response to unsuccessful validation by said pre-processor, said task comprising correcting a deficiency in said collated claim data likely to result in claim denial.

9. A system according to claim 1, wherein

said pre-processor processes said collated claim data to correct a deficiency in said collated claim data likely to result in claim denial, in response to unsuccessful validation by said pre-processor.

10. A system according to claim 1, wherein

said source of rules is at least one of, (a) a remotely located rules source provided by a payer, and (b) a rule repository and

said pre-processor submits said collated claim data for processing with said payer rules using a claim submission procedure provided by said payer.

11. A system according to claim 1, including

a rules accumulator for accumulating rules, to be retained by said source of rules, from at least one of a plurality of sources including, (a) a payer, (b) payer messages, (c) payer websites, (d) a rule creation processor for creating rules in response to previously identified claim data deficiencies and (e) regulatory guidelines.

12. A system according to claim 1, including

a rules processor for processing acquired claim data to identify a condition triggering application of rules.

13. A system according to claim 12, wherein

said rules processor, in response to an identified condition, applies rules for use in editing claim data.

14. A system according to claim 13, wherein

said rules processor applies a first set of rules in response to a first condition state and a second set of rules in response to a second condition state.

15. A system according to claim 12, wherein

said rules processor processes acquired claim data in response to an event including at least one of, (a) generation of a record for incorporation in claim data for a patient, (b) detection of a record addition to claim data for a patient, (c) detection of a record addition to a patient billing record, (d) detection of a change in a patient billing record and (e) detection of a change in claim data for a patient.

16. A system according to claim 12, wherein

said rules processor, in response to application of said rules for use in editing claim data performs at least one of, (a) schedules a task to be performed by a healthcare worker, (b) creates an error report, (c) creates a record of a result of applying said rules for use in editing claim data, (d) creates an accounting report, (e) generates a claim and (f) accepts a remittance.

17. A system according to claim 12, wherein

said rules processor, in response to identification of a condition, initiates scheduling of review of acquired claim data to be performed by a healthcare worker.

18. A system according to claim 1, including

a user interface supporting access to collated claim data by at least one of, (a) a patient, (b) a payer, (c) a healthcare provider, (d) an employer of a patient and (e) a governmental agency.

19. A system according to claim 1, including

an interface processor supporting exchange of data between said system and external entities including at least one of, (a) a patient, (b) a payer, (c) a healthcare provider, (d) an employer of a patient and (e) a governmental agency, said exchange of data being supported by using data format and protocol conversion.

20. A system for processing claim data related to provision of healthcare to a patient, comprising:

a rules processor for automatically creating rules for use in adaptively processing collated claim data in response to previously identified claim data deficiencies and for processing acquired claim data to identify a condition triggering application of a first set of rules for determining validity of an individual claim element;

a claim data collator for collating individual claim element data for a particular patient for submission to a payer;

a source of a second set of rules including automatically created rules for use in processing collated claim data;

a pre-processor for submitting said collated claim data for automatic trial adjudication by a healthcare provider to determine expected adjudication results including expected reimbursement prior to submission for adjudication by a payer using said second set of rules to validate said collated claim data is in condition for processing to initiate generation of payment; and

a claim processor, for submitting said collated claim data to said payer for adjudication by said payer, in response to successful validation by said pre-processor.

21. A system according to claim 20, wherein

said rules processor processes an individual claim element for an individual healthcare encounter in response to a record of said individual healthcare encounter being incorporated into said particular patient collated claim data.

22. A system according to claim 21, wherein

said pre-processor processes said particular patient collated claim data in response to completion of said particular patient collated claim data.

23. A system according to claim 20, wherein

said pre-processor automatically re-submits amended collated claim data for processing using said rules to validate said collated claim data is in condition for processing to initiate generation of payment, said amended collated claim data being received in response to unsuccessful validation using said rules.

24. A system according to claim 20, wherein

said second set of rule includes said first set of rules.

25. A system according to claim 20, wherein

said first set of rules is for use in editing claim data.

26. A method for processing claim data related to provision of healthcare to a patient, comprising the steps of:

creating rules for use in adaptively processing collated claim data in response to previously identified claim data deficiencies;

processing acquired claim data to identify a condition triggering application of rules for determining validity of an individual claim element;

collating data related to a claim for a particular patient for submission to a payer;

pre-processing collated claim data by performing automatic trial adjudication to determine expected adjudication results including expected reimbursement prior to submission for adjudication by a payer using predetermined and created rules to validate said collated claim data is in condition for processing to initiate generation of payment; and

submitting said collated claim data to said payer for adjudication by said payer, in response to successful validation by said pre-processor.

27. A method according to claim 26, including the step of,

re-submitting amended collated claim data for processing using said rules to validate said collated claim data is in condition for processing to initiate generation of payment, said amended collated claim data being received in response to unsuccessful validation using said rules.

28. A system for processing claim data related to provision of healthcare to a patient, comprising:

a claim data collator for collating data related to a claim for a particular patient for submission to a payer;

a source of rules for use in processing collated claim data;

a pre-processor for submitting said collated claim data for automatic trial adjudication by a healthcare provider to determine expected adjudication results including expected reimbursement prior to submission for adjudication by a payer using said rules to validate said collated claim data is in condition for processing to initiate generation of payment; and

a claim processor, for submitting said collated claim data to said payer for adjudication by said payer, in response to successful validation by said pre-processor wherein

said pre-processor obtains a system certification from a payer following successful validation of multiple sets of collated claim data indicating system operation in accordance with payer rules, said certification signifying a threshold level of capability of said system.