Method and system for adjudicating claims in a health service environment

• US 8,121,864 B2
• Filed: 06/09/2006
• Issued: 02/21/2012
• Est. Priority Date: 04/28/2006
• Status: Expired due to Fees

• Current Assignee: MDI Technologies, Inc. (ResMed Incorporated)
• Original Assignee: MDI Technologies, Inc. (ResMed Incorporated)
• Inventors: Green, Jason Reinis, Wood, Raymond Michael, Snyder, Robert John, Willich, Richard R.
• Primary Examiner(s): RANGREJ, SHEETAL
• Application Number:
  US11/449,722
• Publication Number:
  US 20070255590A1
• Time in Patent Office: 2,083 Days
• Field of Search: 705 3- 4
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/109 Time management, e.g. calendars, reminders, meetings or time accounting
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

Methods and systems for adjudicating claims in health services environments are presented. An exemplary method for processing service provider claims for payment includes receiving a claim for payment, automatically identifying candidate appointments from a plurality of scheduled appointments based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments, analyzing the candidate appointments to determine whether to flag the received claim for resolution, and presenting the received claim for payment when at least one of the candidate appointments corresponds to the received claim. Optionally, the method includes automatically identifying already processed claims based on a degree of similarity between service information associated with the already processed claims and the service information associated with the received claim, analyzing the identified already processed claims to determine whether the received claim is a duplicate claim, and flagging potentially duplicate claims for resolution.

Claims

1. A method for processing service provider claims for payment, in a computer system, comprising:

receiving, in the computer system, a claim for payment;

automatically identifying, in the computer system, candidate appointments from a plurality of scheduled appointments stored in a database based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments;

analyzing, in the computer system, the candidate appointments to determine whether to flag the received claim for resolution; and

presenting, in the computer system, the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

2. The method of claim 1, wherein the step of analyzing the candidate appointments comprises displaying the candidate appointments for review by an adjudicator, wherein the adjudicator determines whether to flag the received claim for resolution.

3. The method of claim 2, wherein the step of displaying the candidate appointments for review by an adjudicator comprises displaying the candidate appointments according to respective degrees of similarity to the received claim.

4. The method of claim 2, Wherein the step of displaying the candidate appointments for review by an adjudicator comprises displaying the candidate appointments for review by an adjudicator when none of the candidate appointments directly corresponds to the received claim.

5. The method of claim 1, wherein the step of analyzing the candidate appointments comprises automatically flagging the received claim for resolution when none of the candidate appointments corresponds to the received claim.

6. The method of claim 1, further comprising:

automatically identifying already processed claims based on a degree of similarity between service information associated with the already processed claims and the service information associated with the received claim;

analyzing the identified already processed claims to determine whether the received claim is a duplicate claim; and

flagging potentially duplicate claims for resolution.

7. The method of claim 6, wherein the step of analyzing the identified already processed claims comprises automatically determining whether the received claim is potentially a duplicate claim.

8. The method of claim 6, wherein the step of analyzing the identified already processed claims comprises displaying the identified already processed claims for review by an adjudicator, wherein the adjudicator determines whether the received claim is a duplicate claim.

9. The method of claim 1, further comprising routing flagged claims to at least one trouble shooter for resolution.

10. The system of claim 1 wherein the step of analyzing the candidate appointments comprises determining the appropriateness of the received claim for payment.

11. The system of claim 1 wherein the step of presenting the received claim for payment includes providing the received claim with a unique claim identifier code, providing a unique appointment identifier code of the candidate appointment that corresponds to the particular received claim and associating the unique claim identifier code with the unique appointment identifier code.

12. A method for processing service provider claims for payment, in a computer system, comprising:

receiving, in the computer system, a claim for payment;

storing, in the computer system, appointment information associated with a plurality of scheduled appointments and service information associated with the received claim;

automatically identifying, in the computer system, candidate appointments from the scheduled appointments based on a degree of similarity between the service information associated with the received claim and the appointment information associated with the scheduled appointments; and

presenting, in the computer system, the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

13. The method of claim 12, further comprising analyzing the candidate appointments to determine whether to flag the received claim for resolution.

14. The method of claim 12 wherein the step of presenting the received claim for payment includes providing the received claim with a unique claim identifier code, providing a unique appointment identifier code of the candidate appointment that corresponds to the particular received claim and associating the unique claim identifier code with the unique appointment identifier code.

15. A system for processing service provider claims for payment, comprising:

an intake module configured to receive a claim for payment;

a storage module configured to store appointment information associated with a plurality of scheduled appointments and service information associated with the received claim; and

an adjudication module configured to automatically identify candidate appointments from the scheduled appointments based on a degree of similarity between the service information associated with the received claim and the appointment information associated with the scheduled appointments, wherein the adjudication module is configured to present the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

16. The system of claim 15, wherein the adjudication module is configured to analyze the candidate appointments to determine whether to flag the received claim for resolution.

17. The system of claim 16, wherein the adjudication module is configured to automatically flag the received claim for resolution when none of the candidate appointments corresponds to the received claim.

18. The system of claim 16, further comprising a display device configured to display the candidate appointments for review by an adjudicator, wherein the adjudicator determines whether to flag the received claim for resolution.

19. The system of claim 18, wherein the display device is configured to display the candidate appointments for review by an adjudicator when none of the candidate appointments directly corresponds to the received claim.

20. The system of claim 15 wherein the adjudication module facilitates the determination of the appropriateness of the received claim for payment.

21. A system for processing service provider claims for payment, comprising:

means for receiving a claim for payment; and

means for automatically identifying candidate appointments from a plurality of scheduled appointments based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments, wherein the identifying means is configured to analyze the candidate appointments to determine whether to flag the received claim for resolution and present the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

22. The system of claim 21 wherein the identifying means is configured to provide the received claim with a unique claim identifier code, provide a unique appointment identifier code of the candidate appointment that corresponds to the particular received claim and associate the unique claim identifier code with the unique appointment identifier code.

23. A system for processing service provider claims for payment, in a computer system, comprising:

a processor; and

a computer-readable medium including instructions that, when executed by the processor perform a method, the method including;

receiving, in the computer system, a claim for payment;

storing, in the computer system, appointment information associated with a plurality of scheduled appointments and service information associated with the received claim;

automatically identifying, in the computer system, candidate appointments from the scheduled appointments based on a degree of similarity between the service information associated with the received claim and the appointment information associated with the scheduled appointments; and

presenting, in the computer system, the received claim for payment when at least one of the candidate appointments corresponds to the received claim.

24. The system of claim 23 wherein the step of presenting the received claim for payment includes providing the received claim with a unique claim identifier code, providing a unique appointment identifier code of the candidate appointment that corresponds to the particular received claim and associating the unique claim identifier code with the unique appointment identifier code.