Method and system for scheduling tracking, adjudicating appointments and claims in a health services environment

• US 8,126,738 B2
• Filed: 04/28/2006
• Issued: 02/28/2012
• 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 R
• Application Number:
  US11/412,836
• Publication Number:
  US 20070255586A1
• Time in Patent Office: 2,132 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

An exemplary method for determining the appropriateness of service provider claims for payment includes scheduling appointments for patients with service providers based on requests for services, generating appointment information corresponding to each of the scheduled appointments, and capturing service information corresponding to claims received from the service providers for payment of charges associated with services rendered by the service providers to the patients. The method further includes automatically identifying candidate appointments that correspond to a particular received claim based on a degree of similarity between the service information associated with the particular received claim and the appointment information associated with the scheduled appointments. Additionally, the method includes flagging the particular received claim for resolution when none of the candidate appointments corresponds to the particular received claim, and presenting the particular received claim for payment when at least one of the candidate appointments corresponds to the particular received claim.

Claims

1. A system for determining the appropriateness of service provider claims for payment, comprising:

a scheduling module configured to schedule appointments in a computer for patients with service providers based on requests for services, wherein the scheduling module is further configured to generate appointment information corresponding to each of the scheduled appointments;

a claim intake module configured to receive claims from the service providers for payment of charges associated with services rendered by the service providers to the patients, wherein the claim intake module is further configured to capture service information in a computer corresponding to each of the received claims; and

an adjudication module configured to automatically identify in a computer candidate appointments that correspond to a particular received claim based on a degree of similarity between the service information associated with the particular received claim and the appointment information associated with the scheduled appointments, wherein the adjudication module is further configured to present the particular received claim for payment when at least one of the candidate appointments corresponds to the particular received claim and flag in a computer the particular received claim for resolution when none of the candidate appointments corresponds to the particular received claim.

2. The system of claim 1, wherein the scheduling module further comprises a calendar interface configured to display the scheduled appointments as selectable elements for accessing corresponding appointment information.

3. The system of claim 1, wherein each request for services includes a patient identifier code.

4. The system of claim 1, wherein each request for services includes an authorization code.

5. The system of claim 1, wherein the appointment information includes at least one unique service identifier code for each requested service.

6. The system of claim 1, wherein the appointment information includes a unique appointment identifier code.

7. The system of claim 6, wherein the service information includes a unique claim identifier code.

8. The system of claim 7, wherein the adjudication module is further configured to associate the unique claim identifier code of the particular received claim to the unique appointment identifier code of the candidate appointment that corresponds to the particular received claim.

9. The system of claim 1, wherein the appointment information includes one or more associated file attachments.

10. The system of claim 1, wherein the appointment information includes communication between a system operator and a service provider.

11. The system of claim 1, wherein the service information includes an image of the received claim.

12. The system of claim 1, further comprising an administrator module configured to modify a list of service providers in a network.

13. The system of claim 1, further comprising an administrator module configured to modify access rights to the system.

14. The system of claim 1, further comprising a reporting module configured to generate reports based on aggregated service information.

15. The system of claim 1, further comprising a reporting module configured to identify a pricing structure in a computer by displaying the pricing of services for each provider within a network of service providers.

16. The system of claim 1, further comprising a claim tracking module configured to route flagged claims in a computer from the adjudication module to at least one trouble shooter for resolution.

17. The system of claim 16, wherein the claim tracking module is further configured to compile a history of the routing.

18. The system of claim 16, wherein the claim tracking module is further configured to route resolved flagged claims to the adjudication module for validation ahead of other claims.

19. The system of claim 1, further comprising a claim acquisition module configured to automatically determine in a computer which scheduled appointments have not been identified by the adjudication module as corresponding to particular received claims within a predetermined period of time.

20. The system of claim 19, wherein the claim acquisition module is further configured to queue the scheduled appointments which have not been identified by the adjudication module as corresponding to particular received claims within a predetermined period of time for resolution by at least one system operator.

21. The system of claim 20, wherein the claim acquisition module is further configured to remove a scheduled appointment from the queue when a received claim is identified that corresponds to the scheduled appointment and the identified received claim is forwarded to the adjudication module.

22. The system of claim 20, wherein the claim acquisition module is further configured to automatically determine a number of received claims associated with a particular scheduled appointment and queue the particular scheduled appointment for resolution by the system operator when the adjudication module has identified the particular scheduled appointment as corresponding to fewer than the number of received claims within the predetermined period of time.

23. A method for determining the appropriateness of service provider claims for payment, comprising:

scheduling appointments for patients with service providers based on requests for services;

generating appointment information corresponding to each of the scheduled appointments;

capturing in a computer, service information corresponding to claims received from the service providers for payment of charges associated with services rendered by the service providers to the patients;

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

flagging in a computer, the particular received claim for resolution when none of the candidate appointments corresponds to the particular received claim; and

presenting the particular received claim for payment when at least one of the candidate appointments corresponds to the particular received claim.

24. The method of claim 23, wherein the step of scheduling comprises creating a referral for each of the requests.

25. The method of claim 24, wherein the step of scheduling further comprises assigning a unique referral identification code to each referral.

26. The method of claim 24, wherein the step of scheduling further comprises queuing the referrals in a centralized scheduling queue.

27. The method of claim 26, wherein the step of scheduling further comprises selecting a referral from the centralized scheduling queue and scheduling an appointment for the selected referral.

28. The method of claim 23, wherein the step of scheduling comprises scheduling appointments with service providers identified in a particular network of service providers.

29. The method of claim 23, wherein the step of scheduling comprises scheduling the appointments in accordance with one or more predefined scheduling rules.

30. The method of claim 23, wherein the step of generating appointment information comprises selecting the appointment information from predefined menus of appointment information.

31. The method of claim 23, wherein the step of generating the appointment information comprises calculating a price estimate for a particular requested service.

32. The method of claim 23, wherein the step of generating the appointment information comprises selecting a unique service identifier code for each requested service.

33. The method of claim 23, wherein the step of generating the appointment information comprises assigning a unique appointment identifier code to each of the scheduled appointments.

34. The method of claim 23, wherein the step of generating the appointment information comprises maintaining an audit history for each of the scheduled appointments.

35. The method of claim 23, wherein the step of generating the appointment information comprises attaching associated information files.

36. The method of claim 23, further comprising displaying each scheduled appointment using a calendar interface such that each displayed scheduled appointment can be selected to access corresponding appointment information.

37. The method of claim 23, further comprising sorting the scheduled appointments based on categories of the appointment information and selecting a particular sorted scheduled appointment to view corresponding appointment information and to modify the corresponding appointment information as required.

38. The method of claim 23, wherein the capturing service information step comprises automatically populating a database with service information corresponding to claims received in an electronic format from the service providers.

39. The method of claim 23, wherein the capturing service information step comprises manually entering into the database service information corresponding to claims received in a non-electronic format from the service providers.

40. The method of claim 39, wherein the capturing service information step further comprises manually entering the service information into the database in accordance with a double-blind entry process comprising two data entry personnel entering the same service information wherein neither data entry person observes the data input by the other.

41. The method of claim 39, wherein the capturing service information step further comprises storing in the database images of the claims received in a non-electronic format.

42. The method o claim 23, further comprising sorting the received claims based on categories of the serviced information and selecting a particular received claim to view corresponding service information.

43. The method of claim 23, further generating one or more reports based on aggregated service information.

44. The method of claim 23, wherein the step of automatically identifying candidate appointments comprises routing the particular received claim from an adjudication queue to an initial adjudicator, wherein the particular received claim is routed to another adjudicator if the initial adjudicator does not respond within a predetermined period of time.

45. The method of claim 23, further comprising:

automatically identifying candidate claims that correspond to a particular received claim based on a degree of similarity between the service information associated with the particular received claim and the service information associated with the received claims;

determining the particular received claim is a duplicate claim by analyzing the identified candidate claims; and

flagging duplicate claims for resolution.

46. The method of claim 45, wherein the step of determining if the particular received claim is a duplicate claim comprises automatically determining if the particular received claim is a duplicate claim.

47. The method of claim 23, wherein the step of automatically identifying candidate appointments comprises displaying the candidate appointments for review by an adjudicator, wherein the adjudicator determines whether to flag the particular received claim for resolution or to present the particular received claim for payment.

48. The method of claim 47, wherein the step of displaying candidate appointments for review by an adjudicator comprises displaying candidate appointments for review by an adjudicator when none of the candidate appointments directly corresponds to the particular received claim.

49. The method of claim 23, wherein the steps of flagging the particular received claim for resolution and presenting the particular received claim for payment comprise:

automatically flagging the particular received claim for resolution when none of the candidate appointments corresponds to the particular received claim; and

automatically presented the particular received claim for payment when at least one of the candidate appointments corresponds to the particular received claim.

50. The method of claim 23, wherein the step of flagging the particular received claim for resolution comprises routing the flagged claim to one or more trouble shooters for resolution.

51. The method of claim 50, further comprising compiling a history of the routing of the flagged claim among the trouble shooters.

52. The method of claim 50, further comprising routing resolved flagged claims to an adjudicator for validation ahead of other claims.

53. The method of claim 23, wherein the step of presenting the particular received claim for payment further comprises associating a unique claim identifier code of the particular received claim to a unique appointment identifier code of the candidate appointment that corresponds to the particular received claim.

54. The method of claim 23, wherein the step of presenting the particular received claim for payment further comprises reviewing a pricing signature for a service provider comprising unique information associated with a service provider that assists in verifying the correct pricing and corresponding to the particular received claim to verify a payment amount for services rendered by the service provider.

55. The method of claim 23, wherein the step of presenting the particular received claim for payment further comprises generating a submission report including information about the routing of the particular received claim from the time the service information corresponding to the particular received claim was captured to the time the particular received claim was presented for payment.

56. The method of claim 23, further comprising automatically detecting which scheduled appointments have not been identified as corresponding to any received claims within a predetermined period of time.

57. The method of claim 56, further comprising queuing the scheduled appointments which have not been identified as corresponding to any received claims within a predetermined period of time for resolution by at least one trouble shooter.

58. The method of claim 57, further comprising removing a scheduled appointment from the queue when a received claim is identified that corresponds to the scheduled appointment and the identified received claim is presented for payment.

59. The method of claim 57, further comprising automatically determining an anticipated number of received claims associated with a particular scheduled appointment and queuing the particular scheduled appointment for resolution by the trouble shooter when the particular scheduled appointment corresponds to fewer than the anticipate number of received claims within the predetermined period of time.

60. A non-transitory computer recording medium on which the method for determining appropriateness of service provider claims for payment is recorded as a program code that can be executed by a computer, the method comprising:

scheduling appointments for patients with service providers based on requests for services;

generating appointment information corresponding to each of the scheduled appointments;

capturing in a computer, service information corresponding to claims received from the service providers for payment of charges associated with services rendered by the service providers to the patients;

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

flagging in a computer, the particular received claim for resolution when none of the candidate appointments corresponds to the particular received claim; and

presenting the particular received claim for payment when at least one of the candidate appointments corresponds to the particular received claim.

61. A system for determining the appropriateness of service provider claims for payment, comprising:

means for scheduling appointments for patients with service providers based on requests for services;

means for generating appointment information corresponding to each of the scheduled appointments;

means for capturing service information corresponding to claims received from the service providers for payment of charges associated with services rendered by the service providers to the patients;

means for automatically identifying candidate appointments that correspond to a particular received claim based on a degree of similarity between the service information associated with the particular received claim and the appointment information associated with the scheduled appointments;

means for flagging the particular received claim for resolution when none of the candidate appointments corresponds to the particular received claim; and

means for presenting the particular received claim for payment when at least one of the candidate appointments corresponds to the particular received claim.