Provider data management and claims editing and settlement system

• US 8,065,162 B1
• Filed: 05/06/2004
• Issued: 11/22/2011
• Est. Priority Date: 05/08/2003
• Status: Active Grant

• Current Assignee: Blue Cross And Blue Shield Of South Carolina
• Original Assignee: Blue Cross And Blue Shield Of South Carolina
• Inventors: Curry, Bry
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): Nguyen; Hiep V
• Application Number:
  US10/839,825
• Time in Patent Office: 2,756 Days
• Field of Search: 705/2
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A method and system of submitting healthcare claims for adjudication at the point of service is provided. The system provides methods and secure central storage for providers of healthcare services to maintain user created and maintained patient lists, provider location lists, and superbill forms for healthcare claims submission according to the user'"'"'s unique and individual requirements. The system transmits completed healthcare claims while protecting patient privacy, and provides real-time adjudication of the claims, giving an almost instantaneous claim result in the form of a patient summary receipt back to the point of service at the healthcare provider'"'"'s location. This is achieved through a real-time interface with the enterprise server claims adjudication engine. Customized lists and superbill forms as required by the individual user are also stored on the enterprise server.

Claims

1. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims, said method comprising the steps of:

a) creating provider location data in a provider location module, wherein said provider location module is on an enterprise server at a location that is remote from a provider with whom the provider location data is associated, and said provider location data comprises a list of provider locations of the provider, and a list of health care professionals associated with each of said provider locations, wherein provider location data is presented by the enterprise server to the provider for preparation of a healthcare claim;

b) creating a patient directory in a patient directory module, wherein said patient directory module is present on the enterprise server at a location that is remote from the provider, and wherein the patient directory comprises a plurality of patient names, a patient number unique to each patient name assigned to each patient name of said plurality of patient names, claims histories associated with patient names, and a third party payer associated with each patient name and patient number, wherein data from the patient directory is presented by the enterprise server to the provider for preparation of the healthcare claim;

c) creating a superbill module, wherein said superbill module is present on the enterprise server at a location that is remote from the provider, wherein said superbill module comprises a list of diagnosis codes and a list of treatment codes uniquely associated with each provider location of the provider, and a charge amount for each diagnosis code of the list of diagnosis codes and a charge amount for each treatment code of the list of treatment codes, wherein data from the superbill module is presented by the enterprise server to the provider for preparation of the healthcare claim;

d) the enterprise server preparing the healthcare claim, wherein the enterprise server provides to a user acting on behalf of the healthcare provider at a location that is remote from the enterprise server, the list of provider locations of the healthcare provider, and the user selects a provider location from the list of provider locations at which the provider has provided healthcare services for which the healthcare claim is submitted, and wherein the enterprise server presents to the user the patient directory for the selected provider location, and the user selects a patient identifier from the patient directory, and wherein the enterprise server presents the user with the list of health care professionals associated with the selected provider location, and the list of diagnosis codes and the list of treatment codes associated with the selected provider location, and the user selects a health care professional from the list of health care professionals associated with the selected provider location, and the user selects a diagnosis from the list of diagnosis codes and a treatment from the list of treatment codes associated with the selected provider location;

e) the user confirming the healthcare claim to the enterprise server;

f) adjudicating the healthcare claim in real time, wherein adjudicating the healthcare claim comprises the steps of determining the amount of money to be paid to the provider by a third party payer, and determining the patient'"'"'s financial responsibility to the provider; and

g) presenting to the user in real time a patient summary receipt, said patient summary receipt comprising information on charges submitted for adjudication, charges allowed to the provider by the adjudication, amounts of money to be paid to the provider by the third party payer, and the patient'"'"'s financial responsibility to the provider.

2. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein use of the enterprise server is shared by other healthcare providers, but said other healthcare providers may not access the provider location module or the patient directory module of the healthcare provider.

3. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims in real time as described in claim 2, wherein use of the enterprise server is shared by other healthcare providers, but said other healthcare providers may not access the superbill module or the list of diagnosis codes or the list of treatment codes of the provider.

4. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein use of the enterprise server is shared by other healthcare providers, but said other healthcare providers may not access the superbill module or the list of diagnosis codes or the list of treatment codes of the provider.

5. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein the patient summary receipt provides remarks explaining differences in third party payment responsibility and the amount of the healthcare claim as submitted by the enterprise server.

6. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, further comprising the steps of the enterprise server comparing the list of diagnosis codes with standard diagnosis codes and the list of treatment codes with standard treatment codes, and the enterprise server validating each diagnosis code of the list of diagnosis codes and each treatment code of the list of treatment codes prior to entering the list of diagnosis codes and the list of treatment codes into said superbill module.

7. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein the user confirms the healthcare claim to the enterprise server from the provider location via the internet.

8. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein the enterprise server causes funds for payment of the healthcare claim to be tendered to the provider substantially contemporaneously with the adjudication of the healthcare claim.

9. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 1, further comprising the step of periodically deleting patient names and adding patient names to the patent directory module.

10. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 1, wherein the healthcare claim prepared by the enterprise server comprises the selected provider location, the selected patient name and patient number, the selected health care professional, the selected diagnosis code and the selected treatment code, and wherein the enterprise server associates charges with the selected diagnosis code and the selected treatment code and prepares charges for payment adjudication.

11. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 1, wherein a claims adjudication module of the enterprise server compares the healthcare claim with rules for payment associated with a third party payer selected by the enterprise server from a database comprising rules for payment of multiple third party payers, and wherein the third party payer is associated for payment of the healthcare claim with the patient name and patient number for which the healthcare claim is submitted.

12. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein the enterprise server provides to the user acting on behalf of the healthcare provider at the location that is remote from the enterprise server, the list of provider locations of the healthcare provider, the list of health care professionals associated with the selected provider location, and the list of diagnosis codes and the list of treatment codes associated with the selected provider location via the internet.

13. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 1, wherein the enterprise server is maintained at a physical location operated by the third party payer.

14. A method for managing healthcare provider data and preparation and settlement of healthcare provider claims, said method comprising the steps of:

a) creating a provider patient directory module comprising a patient directory that is unique to a healthcare provider, wherein said patient directory module is present on an enterprise server at a location that is remote from the healthcare provider, wherein the patient directory comprises data comprising a plurality of patient names, a patient number unique to each patient name and assigned to each patient name of said plurality of patient names, and a third party payer associated with each patient name and patient number;

b) creating a provider superbill module, wherein said superbill module is present on the enterprise server at a location that is remote from the healthcare provider, wherein said superbill module comprises data comprising a list of diagnosis codes and a list of treatment codes uniquely associated with a provider location of the healthcare provider as selected by the healthcare provider, and wherein a charge amount is associated with each diagnosis code of the list of diagnosis codes and a charge amount is associated with each treatment code of the list of treatment codes;

c) the enterprise server preparing a healthcare claim for the healthcare provider, wherein the enterprise server assembles data from the patient directory module and data from the superbill module that is associated with the provider location to populate a claim form and the enterprise server transmits the data so assembled from the patient directory module and from the superbill module to a provider computer at a provider location that is remote from the enterprise server, and wherein the enterprise server presents to a user the patient directory for the provider location, and the user selects a patient identifier from the patient directory, and wherein the enterprise server presents the user with a list of health care professionals associated with the provider location, and the list of diagnosis codes and the list of treatment codes associated with the provider location, and the user selects a health care professional from the list of health care professionals associated with the selected provider location, and the user selects a diagnosis from the list of diagnosis codes and a treatment from the list of treatment codes associated with the selected provider location;

d) the user confirming the healthcare claim to the enterprise server; and

e) adjudicating the healthcare claim.

15. A method for managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, said method further comprising the steps of adjudicating the healthcare claim in real time, wherein adjudicating the healthcare claim comprises the steps of determining the amount of money to be paid to the provider by a third party payer in real time, and determining the patient'"'"'s financial responsibility to the provider in real time.

16. A method for managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, said method further comprising the steps of:

adjudicating the healthcare claim in real time, wherein adjudicating the healthcare claim comprises the steps of determining the amount of money to be paid to the provider by a third party payer in real time, and determining the patient'"'"'s financial responsibility to the provider in real time; and

transmitting to the provider computer in real time a patient summary receipt, said patient summary receipt comprising information on charges submitted for adjudication, charges allowed to the provider by the adjudication, amounts of money to be paid to the provider by the third party payer, and the patient'"'"'s financial responsibility to the provider.

17. A method for managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, said method further comprising the steps of creating provider location data for use by a provider in a provider location module, wherein said provider location module is on a enterprise server at a location that is remote from a provider with whom the provider location data is associated, and said provider location data comprises a list of provider locations of the provider, and a list of health care professionals associated with each of said provider locations wherein the enterprise server assembles data from the provider location module to populate the claim form and the enterprise server transmits the data so assembled to the provider computer with the data so assembled from the patient directory module, and a user acting on behalf of the healthcare provider selects a provider location from the list of provider locations.

18. A method for managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, wherein the patient directory module comprises data claims histories associated with the patient names.

19. A method for managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, wherein the enterprise server presents to the user the patient number assigned to the patient name selected by the user, and the third party payer associated with the patient name selected by the user.

20. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein use of the enterprise server is shared by other healthcare providers, but said other healthcare providers may not access the provider location module or the patient directory module of the healthcare provider.

21. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims in real time as described in claim 20, wherein use of the enterprise server is shared by other healthcare providers, but said other healthcare providers may not access the superbill module or the list of diagnosis codes or the list of treatment codes of the provider.

22. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein use of the enterprise server is shared by other healthcare providers, but said other healthcare providers may not access the superbill module or the list of diagnosis codes or the list of treatment codes of the provider.

23. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein the patient summary receipt provides remarks explaining differences in third party payment responsibility and the amount of the healthcare claim as submitted by the enterprise server.

24. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, further comprising the steps of the enterprise server comparing the list of diagnosis codes with standard diagnosis codes and the list of treatment codes with standard treatment codes, and the enterprise server validating each diagnosis code of the list of diagnosis codes and each treatment code of the list of treatment codes prior to entering the list of diagnosis codes and the list of treatment codes into said superbill module.

25. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein the user confirms the healthcare claim to the enterprise server from the provider location via the internet.

26. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein the enterprise server causes funds for payment of the healthcare claim to be tendered to the provider substantially contemporaneously with the adjudication of the healthcare claim.

27. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, further comprising the step of periodically deleting patient names and adding patient names to the patent directory module.

28. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims, as described in claim 14, wherein the healthcare claim prepared by the enterprise server comprises the selected provider location, the selected patient name and patient number, the selected health care professional, the selected diagnosis code and the selected treatment code, and wherein the enterprise server associates charges with the selected diagnosis code and the selected treatment code and prepares charges for payment adjudication.

29. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein a claims adjudication module of the enterprise server compares the healthcare claim with rules for payment associated with a third party payer selected by the enterprise server from a database comprising rules for payment of multiple third party payers, and wherein the third party payer is associated for payment of the healthcare claim with the patient name and patient number for which the healthcare claim is submitted.

30. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein the enterprise server provides to the user acting on behalf of the healthcare provider at the location that is remote from the enterprise server, the list of provider locations of the healthcare provider, the list of health care professionals associated with the selected provider location, and the list of diagnosis codes and the list of treatment codes associated with the selected provider location via the Internet.

31. A method of managing healthcare provider data and preparation and settlement of healthcare provider claims as described in claim 14, wherein the enterprise server is maintained at a physical location operated by the third party payer.