Insurance estimating system

• US 8,407,066 B2
• Filed: 05/05/2008
• Issued: 03/26/2013
• Est. Priority Date: 05/04/2007
• Status: Active Grant

• Current Assignee: TransUnion Corporation
• Original Assignee: Financial Healthcare Systems, LLC
• Inventors: Gentry, Travis W., Estes, Timothy R., Harrison, David L.
• Primary Examiner(s): NGUYEN, TRAN N
• Application Number:
  US12/115,446
• Publication Number:
  US 20080275737A1
• Time in Patent Office: 1,786 Days
• Field of Search: 705/2, 705/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/00 Commerce
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

Disclosed is a computerized method and system for estimating treatment costs for a health care product and/or service for a health care patient. The estimate of health care costs is calculated before the patient is discharged from the facility providing the health care product or service. The estimate of health care costs may also be performed prior to any treatment or admission to the health care facility of the health care patient. The estimate of treatment costs may include a patient payable amount that estimates the cost of the health care product/service that will be the patient'"'"'s responsibility. The health care patient may be billed for the health care product or service prior to discharging the health care patient and/or prior to providing the health care product or service to the health care patient. If desired, a loan for the estimated patient payable amount may be arranged and/or provided to the health care patient to pay for the patient'"'"'s portion of the cost for the health care product and/or service.

Claims

1. A computerized method for estimating treatment related amounts, including treatment costs, contract allowable amounts, and patient payable amounts, of a health care provider for a health care patient to receive a health care product/service comprising:

supplying a computer system that runs computer software, said computer software performing said computerized method for estimating said treatment related amounts of said health care provider for said health care patient to receive said health care product/service, said computer system having computer readable storage media for storing said computer software as well as data entry information, said estimated treatment related amounts including estimated treatment costs, an estimated allowable amount, and an estimated patient payable amount;

entering facility information for a facility that is to provide said health care product/service to said health care patient into said computer software;

entering patient information about said health care patient into said computer software;

entering insurance information about health insurance provided by an insurance company that covers said health care patient into said computer software;

entering health care code information about said health care product/service that is to be provided to said health care patient into said computer software;

entering insurance benefits information for said health insurance that covers said health care patient into said computer software;

performing estimation calculations in said computer software prior to said health care patient being discharged from said facility and prior to final costs for said health care product/service being available from said insurance company such that said estimated treatment related amounts to receive said health care product/service are calculated by taking into account said facility information, said patient information, said insurance information, said insurance benefits information, and said health care code information, said process of performing estimation calculations comprising;

receiving inputs of a contract allowable amount, a maximum deductible amount, a deductible met amount, a co-pay amount, a co-pay-charged-daily-indicator indicating whether said co-pay amount is charged daily, a number of co-pays days value, a co-insurance percentage, a maximum out of pocket, an out of pocket met amount, a deductible-included-in-out-of-pocket-amount-indicator indicating whether a deductible owable amount is included in an out of pocket owed amount, and a co-pay-included-in-out-of-pocket-amount-indicator indicating whether a co-pay due amount is included in said out of pocket owed amount;

calculating said deductible owable amount by subtracting said deductible met amount from said maximum deductible amount;

calculating said co-pay due amount by interrogating said co-pay-charged-daily-indicator and if said co-pay-charged-daily-indicator is true, then;

calculating said co-pay due amount by multiplying said co-pay amount by said number of co-pay days value,

otherwise;

calculating said co-pay due amount by setting said co-pay due amount equal to said co-pay amount;

calculating a co-insurance due amount by subtracting said deductible owable amount and said co-pay due amount from said contract allowable amount to obtain an interim co-insurance due result, and multiplying said interim co-insurance due result by said co-insurance percentage;

calculating said out of pocket owed amount by first interrogating said deductible-included-in-out-of-pocket-amount-indicator and if said deductible-included-in-out-of-pocket-amount-indicator is false, then;

interrogating said co-pay-included-in-out-of-pocket-amount-indicator and if said co-pay-included-in-out-of-pocket-amount-indicator is false, then;

setting said out of pocket owed amount to said maximum out of pocket amount minus said out of pocket met amount,

if said co-pay-included-in-out-of-pocket-amount-indicator is true, then;

setting said out of pocket owed amount to said maximum out of pocket amount minus said out of pocket met amount and minus said co-pay due amount,

if said deductible-included-in-out-of-pocket-amount-indicator is true, then;

interrogating said co-pay-included-in-out-of-pocket-amount-indicator and if said co-pay-included-in-out-of-pocket-amount-indicator is false, then;

setting said out of pocket owed amount to said maximum out of pocket amount minus said out of pocket met amount and minus said deductible owable amount,

if said co-pay-included-in-out-of-pocket-amount-indicator is true, then;

setting said out of pocket owed amount to said maximum out of pocket amount minus said out of pocket met amount and minus said deductible owable amount and minus said co-pay due amount;

comparing said deductible owable amount to said contract allowable amount;

performing a first subset of processes if said deductible owable amount is greater than said contract allowable amount, said first subset of processes comprising;

calculating a deductible payable amount by setting said deductible payable amount equal to said contract allowable amount; and

calculating a payable amount for said health care patient by first comparing said deductible payable amount to said out of pocket owed amount and if said deductible payable amount is greater than said out of pocket owed amount, then;

setting said payable amount equal to said out of pocket owed amount,

otherwise;

calculating said payable amount by setting said payable amount equal to said contract allowable amount; and

performing a second subset of processes if said deductible owable amount is not greater than said contract allowable amount, said second subset of processes comprising;

calculating said deductible payable amount by setting said deductible payable amount equal to said deductible owable amount;

comparing said deductible payable amount plus said co-pay due amount to said contract allowable amount and if said deductible payable amount plus said co-pay due amount is greater than said contract allowable amount, then;

setting said co-insurance due amount to zero, otherwise;

keeping said co-insurance due amount as calculated;

calculating a payable amount for said health care patient by first comparing said deductible payable amount plus said co-insurance due amount to said out of pocket owed amount and if said deductible payable amount plus said co-insurance due amount is greater than said out of pocket owed amount, then;

setting said payable amount equal to said out of pocket owed amount,

otherwise;

calculating said payable amount by setting said payable amount equal to said deductible owed amount plus said co-insurance due amount plus said co-pay due amount;

creating an estimation report in said computer software that shows said estimation calculations; and

delivering said estimation report to an interested party.

2. The computerized method of claim 1:

wherein entering said facility information further comprises selecting a facility from a predefined list of facilities where said health care product/service is to be provided, said predefined list of facilities being stored on said computer readable media that is part of said computer system;

wherein entering insurance information further comprises selecting the insurance company from a predefined list of insurance companies based on said insurance company information, said predefined list of insurance companies being stored on

said computer readable storage media of said computer system, and each entry in said predefined list of insurance companies being associated with a predefined contract such that by selecting the insurance company permits said computer software access to contract details for said selected insurance company;

wherein entering insurance information also further comprises entering insurance policy information into said computer software; and

wherein said entering health care code information further comprises selecting at least one health care code from a pre-defined list of health care codes such that said selected at least one health care code is indicative of said health care product/service to be provided to said health care patient.

3. The computerized method of claim 2 wherein said process of gathering health care code information further comprises:

selecting at least one International Classification of Diseases (ICD) code that provides an upper level description for said at least one health care product/service;

relating said at least one ICD code to at least one Diagnostic Related Groups (DRG)/Medical Severity Diagnostic Related Groups (MSDRG) code such that said selected at least one DRG/MSDRG code provides a low level description for said at least one health care product/service.

4. The computerized method of claim 3 further comprising:

creating said relationship between said at least one International Classification of Disease (ICD) code and said at least one Diagnostic Related Groups (DRG)/Medical Severity Diagnostic Related Groups (MSDRG) code by analyzing historical medical records to determine a historic relationship between said at least one ICD code and said at least one DRG/MSDRG code.

5. The computerized method of claim 2:

wherein said patient information includes at least one of the group comprising;

date of birth, gender, name, and facility account number;

wherein said insurance policy information includes at least one of the group comprising;

insurance policy number and insurance group number;

wherein said health care code information includes health care codes selected from at least one of the group comprising;

International Classification of Diseases (ICD) codes, Diagnostic Related Groups (DRG) codes, Medical Severity Diagnostic Related Groups (MSDRG) codes, Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, health care facility specific codes, doctor specific codes, and proprietary health care codes;

wherein said insurance benefits information includes at least one of the group comprising;

family maximum deductible amount, family deductible met amount, family maximum out of pocket amount, and family out of pocket met amount; and

wherein said interested party includes at least one of the group comprising;

said health care provider, said facility, the insurance company as specified in said insurance information, and said health care patient.

6. The computerized method of claim 2 wherein said contract details define said contract allowable amount for said health care product/service.

7. The computerized method of claim 2 further comprising:

gathering facility information on available facilities;

entering said facility information into said computer software;

creating said predefined list of facilities by said computer software based on said facility information; and

maintaining and updating said facility information using said computer software.

8. The computerized method of claim 1 further comprising:

entering a date of service that defines when said health care product/service is to start for said health patient into said computer software; and

including said date of service in said estimation calculation.

9. The computerized method of claim 2 further comprising:

gathering insurance company contract information on available insurance company contracts;

entering said insurance company contract information into said computer software;

creating said predefined list of insurance company contracts by said computer software based on said insurance company contract information; and

maintaining and updating said insurance company contract information using said computer software.

10. The computerized method of claim 1 further comprising delivering said estimation report prior to providing said health care product/service to said health care patient.

11. The computerized method of claim 10 further comprising:

collecting payment from said health care patient for said estimated patient payable amount owed by said health care patient prior to providing said health care product/service to said health care patient.

12. The computerized method of claim 1 wherein said estimated treatment costs of said estimated treatment related amounts are further based on historical costs for said health care product/service of said health care provider.

13. The computerized method of claim 12 wherein said historical costs include at least one of the group comprising:

average price, median price, average length of stay, median length of stay, average implant/material cost, and median implant/material cost.

14. The computerized method of claim 1 wherein said process of performing estimation calculations in said computer software and said process for creating said estimation report are performed prior to said health care product/service being rendered to said health care patient.

15. The computerized method of claim 1 further comprising collecting payment from said health care patient for said estimated patient payable amount owed by said health care patient prior to discharging said patient from said selected facility, said estimated patient payable amount being a part of said estimated treatment related amounts.

16. The computerized method of claim 1 further comprising:

providing access to at least one loan company to said health care patient;

delivering said estimation report containing said estimated patient payable amount owed by said health care patient to said at least one loan company such that said health care patient is able to qualify for a loan from said at least one loan company; and

collecting payment from proceeds of a loan provided by said at least one loan company prior to said health care patient being discharged from said selected facility.

17. The computerized method of claim 1 further comprising:

qualifying said health care patient for a loan in an amount equal to said estimated patient payable amount owed by said health care patient prior to said health care patient being discharged from said selected facility;

providing said health care patient said loan for said estimated patient payable amount for said health care product/service if said health care patient qualifies for said loan; and

paying said estimated patient payable amount for said health care product/service with proceeds of said loan in said amount equal to said estimated patient payable amount prior to said health care patient being discharged from said selected facility.

18. The computerized method of claim 1 further comprising selecting said health care provider from a predefined list of health care providers, said predefined list of health care providers being stored on said computer readable media that is part of said computer system.