Medical claims fraud prevention system including patient call initiating feature and associated methods

• US 8,392,211 B2
• Filed: 07/08/2010
• Issued: 03/05/2013
• Est. Priority Date: 07/28/2005
• Status: Active Grant

• Current Assignee: Beraja IP LLC
• Original Assignee: Beraja IP LLC
• Inventors: Beraja, Roberto, Beraja, Victor, Beraja, Esther, Beraja, Isidoro, Beraja, Matilde
• Primary Examiner(s): PAULS, JOHN A
• Application Number:
  US12/832,427
• Publication Number:
  US 20100332252A1
• Time in Patent Office: 971 Days
• Field of Search: 705/2, 705/16, 705/50, 364/406, 235/382
• US Class Current: 705/2
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A medical claim fraud prevention system includes a first controller positioned at a medical facility and a second controller positioned at a patient information collection center and adapted to be in communication with the first controller. The first controller may transmit a first signal to the second controller responsive to an occurrence of a predetermined event. The second controller may initiate contact with a patient via the patient'"'"'s mobile phone in response to the first signal received from the first controller, and the patient may be prompted to enter predetermined information to verify their location. The second controller may transmit an indication to the first controller in response to the first signal received from the first controller regarding whether the patient is within a predetermined vicinity of the medical facility based on the predetermined information entered by the patient to verify their location.

Claims

1. A medical claim fraud prevention system comprising:

a first controller positioned at a medical facility;

a second controller positioned at a patient information collection center and adapted to be in communication with the first controller; and

—

a medical software system adapted to be in communication with the first controller;

wherein the medical software system prompts a user to enter medical information related to a patient;

wherein the medical software system sends the medical information related to the patient to the first controller;

wherein the first controller sends a signal requesting the location of the patient to the second controller responsive to the information received from the medical software system;

wherein the second controller initiates contact with the patient via a mobile telephone of the patient in response to the signal received from the first controller;

wherein the patient is prompted to enter information into the patient'"'"'s mobile telephone;

wherein the second controller receives information from the patient'"'"'s mobile telephone, the information providing an indication of the patient'"'"'s location; and

wherein the second controller determines information received from the patient'"'"'s mobile telephone properly identifies the patient and indicates the patient'"'"'s location being within a vicinity of the medical facility; and

wherein the second controller transmits an indication to the first controller in response to the first signal received from the first controller regarding whether the patient is within a vicinity of the medical facility based on the determination as to whether the information received from the patient'"'"'s mobile telephone properly identifies the patient and indicates the patient'"'"'s location being within a vicinity of the medical facility.

2. A system according to claim 1 wherein the medical software system is at least one of a billing system and a patient information collection system.

3. A system according to claim 1 wherein the medical facility is at least one of a doctor'"'"'s office, a hospital, a pharmacy, a therapy center, a medical laboratory, a medical clinic, a rehabilitation facility, a dialysis unit, an outpatient center, an assisted care living facility, an emergency room and a nursing home.

4. A system according to claim 1 wherein the patient information collection center is associated with processing health insurance claims.

5. A system according to claim 1 wherein the signal transmitted from the first controller to the second controller includes information relating to a claim for reimbursement relating to medical services being provided to the patient at the medical facility.

6. A system according to claim 5 wherein the second controller transmits a signal to the first controller including an indication of whether or not the claim is a valid claim based on the indication of whether the patient is within the vicinity of the medical facility.

7. A system according to claim 1 wherein the information that the patient is prompted to enter is a personal identification number.

8. A system according to claim 1 wherein the information that the patient is prompted to enter is pressing a number on the telephone in response to a question presented to the patient.

9. A system according to claim 1 wherein the information that the patient is prompted to enter is a verbal response to a question presented to the patient.

10. A system according to claim 1 further comprising a backup locating system that is activated to perform an action based on a backup event.

11. A system according to claim 10 wherein the backup event that activates the backup locating system is an indication from the second controller that the patient is not within the vicinity of the medical facility based on the information entered by the patient to verify their location.

12. A system according to claim 10 wherein the action is at least one of calling the patient'"'"'s mobile telephone and speaking with the patient to determine the location of the patient, and providing a notification to the medical facility including a request that the patient contact the patient information collection center to verify the patient'"'"'s location.

13. A system according to claim 10 wherein the action is calling the medical facility and requiring the patient to verify their location using a patient identifier.

14. A system according to claim 10 wherein the action is calling the medical facility and speaking with the patient, and requiring the patient to verify their location using a patient identifier.

15. A method of preventing medical claim fraud, the method comprising:

prompting a user to enter medical information related to a patient using a medical software system;

transmitting the patient information received by the medical software system to a first controller positioned at a medical facility that includes a user interface;

transmitting a signal from the first controller to a second controller positioned at a patient information collection center responsive to the patient information received by the first controller from the medical software system, wherein the second controller is adapted to be in communication with the first controller;

initiating a telephone call to a mobile telephone of the patient;

prompting a patient to enter information into the mobile telephone, wherein the information provides an indication an indication of the patient'"'"'s location; and

transmitting an indication from the second controller to the first controller in response to the first signal received from the first controller of whether the patient is within a vicinity of the medical facility based on a determination as to whether the information received from the patient'"'"'s mobile telephone properly identifies the patient and indicates the patient'"'"'s location being within a vicinity of the medical facility.

16. A method according to claim 15 wherein the medical software system is at least one of a billing system and a patient information collection system.

17. A method according to claim 15 wherein the medical facility is at least one of a doctor'"'"'s office, a hospital, a pharmacy, a therapy center, a medical laboratory, a medical clinic, a rehabilitation facility, a dialysis unit, an outpatient center, an assisted care living facility, an emergency room and a nursing home.

18. A method according to claim 15 wherein the patient information collection center is associated with processing health insurance claims.

19. A method according to claim 15 wherein the signal transmitted from the first controller to the second controller includes information relating to a claim for reimbursement relating to medical services being provided to the patient at the medical facility.

20. A method according to claim 19 further comprising transmitting a signal from the second controller transmits to the first controller including an indication of whether or not the claim is a valid claim based on the indication of whether the patient is within the vicinity of the medical facility.

21. A method according to claim 15 wherein the information that the patient is prompted to enter is a personal identification number.

22. A method according to claim 15 wherein the information that the patient is prompted to enter is pressing a number on the telephone in response to a question presented to the patient.

23. A method according to claim 15 wherein the information that the patient is prompted to enter is a verbal response to a question presented to the patient.

24. A method according to claim 15 further comprising activating a backup locating system to perform an action based on a backup event.

25. A method according to claim 24 wherein the backup event that activates the backup locating system is an indication received from the second controller that the patient is not within the vicinity of the medical facility.

26. A method according to claim 24 wherein the action is at least one of calling the patient'"'"'s mobile telephone and speaking with the patient to determine the location of the patient, and providing a notification to the medical facility including a request that the patient contact the patient information collection center to verify the patient'"'"'s location.

27. A method according to claim 24 wherein the action is calling the medical facility and requiring the patient to verify their location using a patient identifier.

28. A method according to claim 24 wherein the action is calling the medical facility and speaking with the patient, and requiring the patient to verify their location using a patient identifier.