Method and apparatus for repricing a reimbursement claim against a contract

• US 8,160,905 B2
• Filed: 12/22/2010
• Issued: 04/17/2012
• Est. Priority Date: 10/14/1999
• Status: Expired due to Term

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Lesswing, Mark, Hoerle, Dale
• Primary Examiner(s): Frenel, Vanel
• Application Number:
  US12/975,647
• Publication Number:
  US 20110153371A1
• Time in Patent Office: 482 Days
• Field of Search: 705/4, 705/2, 705/35, 705/36, 705/37
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/04 Trading; Exchange, e.g. stocks, commodities, derivatives or currency exchange
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method for repricing a reimbursement claim under at least one contract is provided herein. The method includes converting each contract into a series of contractual terms, where each contractual terms contains qualification codes, calculation codes and priority notes. The method then converts a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes. The method then begins to compare comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract and when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, the method identifies the contractual term as a matching contractual term associated to the claim line. Upon identifying all matching contractual terms, either to the claim line or the entire claim, the method will determine any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions. The method then calculates the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms. The method may then determine and make any adjustments depending upon any discount terms for the entire reimbursement amount.

Claims

1. A method of repricing at least one reimbursement claim for medical services under at least one contract, comprising:

receiving, by a computer platform, each contract of the at least one contract, each contract containing a contract identifier code and a series of contractual terms, each contractual term being defined by qualification codes, calculation codes, and at least one priority note;

receiving, by the computer platform, each claim of the at least one claim, each claim containing a claim identifier code and a series of claim lines, each claim line being defined by a claim code, a unit number, and a corresponding charge;

repricing, by the computer platform, a claim of the at least one claim by determining a reimbursement amount for the claim; and

displaying the reimbursement amount for the repriced claim.

2. The method of claim 1 wherein the step of determining a reimbursement amount includes

comparing each claim code of the claim against each qualification code of each contractual term of a contract;

when a qualification code of a contractual term is satisfied by a claim code of a claim line, identifying the contractual term as a matching contractual term associated to the claim line, and creating a list of all matching contractual terms;

determining any priority conditions associated to the matching contractual terms, and eliminating any matching contractual terms from said list of matching terms that are excluded by said priority conditions; and

determining a reimbursement charge for each claim line associated to a non-eliminated matching term, and adding the reimbursement charges for the claim lines, wherein the reimbursement amount for the claim is a sum of the reimbursement charges.

3. The method of claim 2 wherein determining any priority conditions further includes

categorizing the contractual terms of each contract into a set of sequentially listed pre-defined sections, wherein the pre-defined sections have a hierarchy that lists a pre-defined section having priority over another pre-defined section before the other pre-defined section.

4. The method of claim 3 wherein determining any priority conditions further includes

arranging the contractual terms categorized in each pre-defined section in a reverse hierarchy, wherein a contractual term having priority over another contractual term is listed subsequent to the other contractual term.

5. The method of claim 3 wherein the step of comparing each claim code against each qualification code includes

when the claim further contains a claim priority condition, comparing each claim code only against qualification codes of contractual terms listed in pre-defined sections that satisfy the claim priority condition.

6. The method of claim 5 wherein the priority conditions include a claim priority condition which eliminates any matching contractual terms listed in a pre-defined section excluded by the claim priority condition.

7. The method of claim 6 wherein when a priority note associated to a matching contractual term indicates that said matching contractual term reprices an entire claim, eliminating all other matching contractual terms.

8. The method of claim 7 wherein the reverse hierarchy is determined by priority notes associated to each contractual term categorized in a pre-defined section.

9. The method of claim 2 wherein the step of requesting the platform to reprice a claim further includes

comparing the claim identifier code of each claim against the contract identifier code of each contract;

and

when the claim identifier code of a claim is substantially equal to a contract identifier code of a contract, identifying the contract as a governing contract and determining a reimbursement amount of the claim only against the governing contract.

10. The method of claim 9 wherein the step of determining a reimbursement amount of the claim only against the governing contract includes

when at least two contracts are identified as governing contracts, repricing the claim against each governing contract creating a list of governing reimbursement amounts, wherein the reimbursement amount of the claim is the lowest governing reimbursement amount.

11. The method of claim 10 further including

storing the reimbursement amount and the claim as a repriced claim.

12. The method of claim 11 wherein, prior to determining the reimbursement amount for a claim, the method including

comparing the claim identifier code of the claim against the claim identifier codes of all stored repriced claims;

when the claim identifier code of the claim is substantially equal to the claim identifier codes of a stored repriced claim, creating a bundled claim having the combined claim lines of the claim lines of the claim with the claim lines of the repriced claim;

determining the reimbursement amount of the bundled claim instead of determining the reimbursement amount of the claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.

13. A computer readable storage medium storing computer readable instructions thereon that, when executed by a computer, direct the computer to perform a method of repricing at least one reimbursement claim for medical services under at least one contract, comprising:

receiving, by the computer, each contract of the at least one contract, each contract containing a contract identifier code and a series of contractual terms, each contractual term being defined by qualification codes, calculation codes, and at least one priority note;

receiving, by the computer, each claim of the at least one claim, each claim containing a claim identifier code and a series of claim lines, each claim line being defined by a claim code, a unit number, and a corresponding charge;

repricing, by the computer, a claim of the at least one claim by determining a reimbursement amount for the claim; and

displaying the reimbursement amount for the repriced claim.

14. A computing apparatus for repricing at least one reimbursement claim for medical services under at least one contract, comprising:

a computer configured to

receive each contract of the at least one contract, each contract containing a contract identifier code and a series of contractual terms, each contractual term being defined by qualification codes, calculation codes, and at least one priority note,

receive each claim of the at least one claim, each claim containing a claim identifier code and a series of claim lines, each claim line being defined by a claim code, a unit number, and a corresponding charge, and

reprice a claim of the at least one claim by determining a reimbursement amount for the claim; and

a display that displays the reimbursement amount for the repriced claim.