Method and system for acquiring claims in a health services environment

• US 8,121,865 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:
  US11/449,724
• Publication Number:
  US 20070255591A1
• Time in Patent Office: 2,083 Days
• Field of Search: 705 2- 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 acquiring claims in health services environments are presented. An exemplary method for processing service provider claims for payment includes: scheduling appointments with the service providers, receiving claims from the service providers, analyzing the scheduled appointments to identify at least one scheduled appointment corresponding to each of the received claims, automatically detecting scheduled appointments not identified as corresponding to any of the received claims within a predetermined period of time, and notifying respective service providers that no claims have been received for the detected scheduled appointments. Optionally, the method includes analyzing appointment information associated with a scheduled appointment to determine an anticipated number of received claims corresponding to the scheduled appointment, and automatically flagging the scheduled appointment for resolution when the scheduled appointment is identified as corresponding to fewer than the anticipated number of received claims within a predetermined period of time.

Claims

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

storing, in a database, appointment information corresponding to and generated from scheduled appointments for one or more potential future claimants with service providers;

storing, in the database, service information corresponding to and generated from claims received from the service providers;

analyzing the appointment information and service information, in the computer system, to identify at least one scheduled appointment corresponding to each of the received claims;

automatically detecting, in the computer system, scheduled appointments not identified as corresponding to any of the received claims within a predetermined period of time; and

queuing the detected scheduled appointments for subsequent notification to respective service providers that no claims have been received for the detected scheduled appointments.

2. The method of claim 1, further comprising queuing the detected scheduled appointments for resolution by at least one trouble shooter.

3. The method of claim 2, further comprising removing a detected scheduled appointment from the queue when the detected scheduled appointment is identified as corresponding to a received claim.

4. The method of claim 1, further comprising:

analyzing the appointment information associated with a scheduled appointment to determine an anticipated number of received claims corresponding to the scheduled appointment; and

automatically flagging, in the computer system, the scheduled appointment for resolution when the scheduled appointment is identified as corresponding to fewer than the anticipated number of received claims within a predetermined period of time.

5. The system of claim 1 wherein the step of analyzing the appointment information and service information includes presenting the received claim for payment.

6. The system of claim 5 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.

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

a storage module, in the computer system, configured to store appointment information corresponding to and generated from scheduled appointments for one or more potential future claimants with service providers in a database, and configured to store service information corresponding to and generated from claims received from the service providers in the database;

a claim intake module, in the computer system, configured to receive claims from the service providers;

an adjudication module, in the computer system, configured to identify at least one scheduled appointment corresponding to each of the received claims; and

a claims acquisition module, in the computer system, configured to automatically detect scheduled appointments not identified by the adjudication module as corresponding to any of the received claims within a predetermined period of time and notify respective service providers that no claims have been received for the detected scheduled appointments.

8. The system of claim 7, wherein the claims acquisition module is configured to queue the detected scheduled appointments for resolution by at least one trouble shooter.

9. The system of claim 8, wherein the claims acquisition module is configured to remove a detected scheduled appointment from the queue when the detected scheduled appointment is identified as corresponding to a received claim.

10. The system of claim 7, wherein the claims acquisition module is further configured to analyze appointment information associated with a scheduled appointment to determine an anticipated number of received claims corresponding to the scheduled appointment, and automatically flag the scheduled appointment for resolution when the adjudication module identifies the scheduled appointment as corresponding to fewer than the anticipated number of received claims within a predetermined period of time.

11. The system of claim 7 wherein the adjudication module is configured to present the received claim for payment, including 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 system for processing service provider claims for payment, in a computer system, comprising:

means for storing appointment information corresponding to and generated from appointments scheduled with the service providers;

means for storing service information corresponding to and generated from claims received from the service providers;

means for analyzing the scheduled appointments to identify at least one scheduled appointment corresponding to each of the received claims; and

means for automatically detecting scheduled appointments not identified by the analyzing means as corresponding to any of the received claims within a predetermined period of time and notifying respective service providers that no claims have been received for the detected scheduled appointments.

13. The system of claim 12, further comprising means for queuing the detected scheduled appointments for resolution by at least one trouble shooter.

14. The system of claim 13, further comprising means for removing a detected scheduled appointment from the queue when the detected scheduled appointment is identified as corresponding to a received claim.

15. The system of claim 12, further comprising:

means for analyzing appointment information associated with a scheduled appointment to determine an anticipated number of received claims corresponding to the scheduled appointment; and

means for automatically flagging, in the computer system, the scheduled appointment for resolution when the scheduled appointment is identified as corresponding to fewer than the anticipated number of received claims within a predetermined period of time.

16. 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;

storing appointment information corresponding to and generated from scheduled appointments for one or more potential future claimants with service providers;

storing service information corresponding to and generated from claims received from the service providers;

analyzing the appointment information and service information to identify at least one scheduled appointment corresponding to each of the received claims;

automatically detecting scheduled appointments not identified as corresponding to any of the received claims within a predetermined period of time; and

queuing the detected scheduled appointments for subsequent notification to respective service providers that no claims have been received for the detected scheduled appointments.

17. The system of claim 16, wherein the detected scheduled appointments are queued for resolution by a least one trouble shooter.

18. The system of claim 17, wherein a detected scheduled appointment is removed from the queue when the detected scheduled appointment is identified as corresponding to a received claim.

19. The system of claim 16, further comprising:

analyzing the appointment information associated with a scheduled appointment to determine an anticipated number of received claims corresponding to the scheduled appointment; and

automatically flagging the scheduled appointment for resolution when the scheduled appointment is identified as corresponding to fewer than the anticipated number of received claims within a predetermined period of time.

20. The system of claim 16 wherein the step of analyzing the appointment information and service information includes presenting the received claim for payment.

21. The system of claim 20 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.