Lossless account compression for health care patient benefits eligibility research system and methods

• US 8,326,656 B2
• Filed: 09/13/2010
• Issued: 12/04/2012
• Est. Priority Date: 02/17/2005
• Status: Active Grant

• Current Assignee: TransUnion Corporation
• Original Assignee: E-Scan Data Systems, Inc.
• Inventors: Beery, Peter Douglas, Considine, Michael L., MacArtney-Filgate, Bruce C., Wester, John William
• Primary Examiner(s): Dunham, Jason
• Assistant Examiner(s): Altschul, Amber
• Application Number:
  US12/880,978
• Publication Number:
  US 20110066447A1
• Time in Patent Office: 813 Days
• Field of Search: 705 2- 4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

A system and method for determining eligibility for reimbursement for medical claims for patients may be implemented with computer software which compares a service provider'"'"'s patient information against a benefit provider'"'"'s database of covered persons to determine if the patient is eligible for benefits. The service provider records may be compressed by grouping all of the medical claims relating to a particular patient into one cluster represented by a composite medical claim, which may be used to query the benefit provider databases to determine if the patient is recognized. If the patient is recognized, every record within the cluster may be checked against the benefit provider'"'"'s database to determine whether one or more patient medical claims are eligible for reimbursement.

Claims

1. A tangible, non-transitory computer program product having a computer readable medium with a computer program embodied thereon, the computer program comprising computer-executable instructions for:

a. sorting medical claims of a service provider into a first group of claims based on one or more selected fields of information contained in said medical claims, said one or more selected fields comprising a unique patient identifier or one or more selected patient demographics;

b. creating a composite medical claim containing all of said one or more selected fields, said composite medical claim comprising a collection of data representative of all medical claims within a group of medical claims all relating to the same patient;

c. formatting the composite medical claim such that data associated with at least one field of the composite medical claim is formatted for comparison with a benefit provider'"'"'s database;

d. executing a first query against the benefit provider'"'"'s database using said data associated with at least one field of the composite medical claim;

e. receiving an indication as to whether the benefit provider'"'"'s database contains a record that is responsive to the first query; and

f. wherein the indication is affirmative, executing a second query against the benefit provider'"'"'s database using data from an individual claim included in the first group of claims.

2. The computer program product of claim 1 wherein said computer-executable instructions further comprise instructions for formatting another medical claim of the service provider for comparison with the benefit provider'"'"'s database, wherein said another medical claim is not within the first group of claims.

3. The computer program product of claim 1 wherein said composite medical claim is formatted in an EDI 270 batch file format.

4. The computer program product of claim 1 wherein at least one of said first query and said second query searches for partial matches of data in multiple different fields.

5. The computer program product of claim 1 wherein at least one of said first query and said second query searches for a subset of data associated with a field.

6. The computer program product of claim 1 wherein identification of at least one associated record in the benefit provider'"'"'s database is based on whether the at least one associated record and the composite medical claim contain a predefined number of parameters that match.

7. A tangible, non-transitory computer program product having a computer readable medium with a computer program embodied thereon, the computer program comprising computer-executable instructions for:

a. sorting medical claims for a single patient of a service provider into a group of claims;

b. creating a composite medical claim which is representative of all of said group of claims, said composite medical claim comprising a collection of data representative of all medical claims within a group of medical claims all relating to the same patient;

c. formatting the composite medical claim such that data associated with at least one field of the composite medical claim is formatted for comparison with a benefit provider'"'"'s database;

d. executing a query against the benefit provider'"'"'s database using data from the composite medical claim, wherein said query compares data in at least one field of the composite medical claim with the benefit provider'"'"'s database; and

e. wherein a record in the benefit provider'"'"'s database is responsive to the query, adding each of the group of claims to a first file.

8. The computer program product of claim 7 wherein said instructions further comprise executing a plurality of queries against the benefit provider'"'"'s database based on each claim of the group of claims.

9. The computer program product of claim 8 wherein said instructions further comprise tracking whether each of said plurality of queries yields any matching records from the benefit provider'"'"'s database.

10. The computer program product of claim 9 wherein said instructions further comprise stopping running the plurality of queries wherein the plurality of queries does not yield any matching records from the benefit provider'"'"'s database.

11. The computer program product of claim 8 wherein said instructions further comprise repeatedly executing one or more of the plurality of queries against the benefit provider'"'"'s database at one or more regular time intervals.

12. The computer program product of claim 11 wherein the one or more regular time intervals are bi-weekly or monthly.

13. The computer program product of claim 11 wherein at least one claim in said first file is related to a newborn baby.

14. A tangible, non-transitory computer program product having a computer readable medium with a computer program embodied thereon, the computer program comprising computer-executable instructions for:

a. sorting medical claims of a service provider for a plurality of individual patients into multiple groups of claims wherein each group of claims pertains to a single patient;

b. for each group of claims, creating a composite medical claim that is representative of all claims within the group, said composite medical claim comprising a collection of data representative of all medical claims within a group of medical claims all relating to the same patient;

c. organizing the composite medical claims such that data associated with at least one field for each composite medical claim is formatted for comparison with a benefit provider'"'"'s database;

d. executing a first plurality of queries using data from the plurality of composite medical claims, wherein each individual query in said first plurality of queries compares data in at least one field of a composite medical claim with the benefit provider'"'"'s database; and

e. wherein a responsive record in the benefit provider'"'"'s database is identified in response to one of the queries associated with a given group of claims, adding the claims that make up the given group of claims to a first file.

15. The computer program product of claim 14 wherein said instructions further comprise executing a second plurality of queries against the benefit provider'"'"'s database using data from claims in the first file, wherein the second plurality of queries includes a query based on patient identity and a query to determine whether a date on which a service was provided to a given patient falls within a range of dates for which coverage was provided by the benefit provider to the given patient.

16. The computer program product of claim 15 wherein the query to determine whether a date on which a service was provided to a given patient falls within a range of dates for which coverage was provided by the benefit provider to the given patient is run only wherein the query based on patient identity returns at least one matched record from the benefit provider'"'"'s database.

17. The computer program product of claim 15 wherein said instructions further comprise adding claims for which a matching record is found in the benefit provider'"'"'s database to a second file.

18. The computer program product of claim 17 wherein a report is created from said second file which identifies a difference in information between a claim of the service provider and a record of the benefit provider.

19. The computer program product of claim 17 wherein said instructions further comprise correcting a claim of the service provider for which an error was identified thereby creating a corrected claim.

20. The computer program product of claim 19 wherein said instructions further comprise re-submitting the corrected claim to the benefit provider for reimbursement.