Benefit management

• US 8,515,781 B2
• Filed: 04/09/2009
• Issued: 08/20/2013
• Est. Priority Date: 10/15/2003
• Status: Active Grant

• Current Assignee: Peter L. Hauser
• Original Assignee: Peter L. Hauser
• Inventors: Kaehler, Peter J., Erickson, John L., Steidel, Leonard R., Hauser, Peter L.
• Primary Examiner(s): Dunham, Jason
• Assistant Examiner(s): MISIASZEK, AMBER ALTSCHUL
• Application Number:
  US12/421,397
• Publication Number:
  US 20090204448A1
• Time in Patent Office: 1,594 Days
• Field of Search: 705 2- 4
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 10/1057 Benefits or employee welfare, e.g. insurance, holiday or retirement packages
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 40/12 Accounting

Abstract

Methods, devices and systems are provided for benefit management. One system includes a server including an application interface and access to a data store having one or more client files. A client file can include a definable set of business rules for managing and administering benefits and can include fund use rules for accessing and applying funds to claims from one or more accounts. The system includes a program operable on the server to apply the definable set of business rules in connection with processing a claim.

Claims

1. A system for benefits management, comprising:

a server including an application interface and access to a data store having one or more client files, wherein a client file includes system user definable sets of business rule instructions executed by a processor to manage and administer benefits and includes fund use rule instructions executed by a processor to access and apply funds to payment of claims from a plurality of accounts; and

a program operable on the server to apply the system user definable sets of business rules to select a hierarchy for payment from the plurality of accounts,

wherein the instructions are executed by the processor to;

allow a plan sponsor to define a first defined set of the fund use rules in order to define and make electronic payment directly to a first part of a non-carrier claim category portion of an electronically transmitted claim, according to control rights and ranking provided first to the plan sponsor for establishing a first tier of the hierarchy for electronic payment of the first part of the non-carrier claim category portion, from between two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan sponsor ranking, indicating a numerical ranking, between the two or more different accounts;

allow a plan sponsor to define a second defined set of the fund use rules in order to define and make electronic payment directly to a second part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided first to the plan sponsor for establishing a second tier of the hierarchy for electronic payment of the second part of the non-carrier claim category portion, from between two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan sponsor ranking, indicating a numerical ranking, between the at least two different accounts;

allow a plan member to define a third defined set of the fund use rules in order to define and make electronic payment directly to a remaining amount of the first part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided second to the plan member as part of the first tier of the hierarchy for further electronic payment of the first part of the non-carrier claim category portion, from between the two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan member ranking, indicating a numerical ranking, between the two or more different accounts;

allow a plan member to define a fourth defined set of the fund use rules in order to define and make electronic payment directly to a remaining amount of the second part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided second to the plan member as part of the second tier of the hierarchy for further electronic payment of the second part of the non-carrier claim category portion, from between the two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan member ranking, indicating a numerical ranking, between the two or more different accounts;

receive the electronically transmitted claim;

apply the plan sponsor ranking and the plan member ranking automatically between the two or more accounts to make payment on the first part of the electronically transmitted claim based on the first tier of the hierarchy; and

apply the plan sponsor ranking and the plan member ranking automatically between the two or more accounts to make payment on the second part of the electronically transmitted claim based on the second tier of the hierarchy.

2. The system of claim 1, wherein the at least two different employee benefit accounts are selected from the group of:

a health reimbursement arrangement (HRA) account;

a flex spending account (FSA);

a vacation account;

a fitness club account;

a retiree health benefits account; and

a salon account.

3. The system of claim 1, wherein:

the first part is a co-pay part of the non-carrier claim category portion of the electronically transmitted claim; and

the second part is a co-insurance part of the non-carrier claim category portion of the electronically transmitted claim.

4. The system of claim 1, wherein the one or more client files include plan sponsor files associated with a health care insurance plan.

5. The system of claim 4, wherein the program can track adjudicated claims submitted by a plan member and can apply the definable set of business rules to manage available funds and track payments in a flexible spending account (FSA) and a health reimbursement arrangement (HRA) account secondary to application of a plan carrier'"'"'s business rules for the health care insurance plan.

6. The system of claim 1, wherein the instructions are executed by the processor to:

allow changes and different definition to the plan sponsor ranking and the plan member ranking between the two or more accounts to establish different first tiers of the hierarchy and different second tiers of the hierarchy between selected categories within particular classes of services; and

automatically apply changes and different definitions according to the different first tiers of the hierarchy and different second tiers of the hierarchy between selected categories within particular classes of services to make payment on the first and the second part of the electronically transmitted claim.

7. The system of claim 6, wherein the selected categories include categories selected from the group of:

an insured category;

a co-insurance category; and

an ineligible category.

8. The system of claim 6, wherein particular classes of services include in-network classes and out-of-network classes for services selected from the group of:

a preventive care service;

an office visit;

a hospital service;

an urgent care center service;

a prescription service;

a dental service;

a vision service;

a chemical dependency service; and

an emergency room service.

9. The system of claim 1, wherein the instructions are executed by the processor to allow and apply a plan sponsor rule

to define and make electronic payment directly to the first part and the second part of a non-carrier claim category portion of the electronically transmitted claim in the form of a percentage payment amount or a fixed payment amount independently among the first part and the second part, and independently among selected categories within particular classes of services.

10. The system of claim 1, wherein the instructions are executed by the processor to:

allow the plan sponsor to delegate control rights and ranking between the plan sponsor and the plan member.

11. The system of claim 1, wherein the one or more client files include one or more member files accessible from a remote device by one or more entities having authorized access rights, the one or more entities selected from the group of:

a plan sponsor;

a plan member; and

a third party administrator.

12. The system of claim 1, wherein each client file is associated with a plan sponsor and wherein the plan sponsor can access its associated client file from a remote device to select among the definable set of business rules.

13. A non-transitory computer readable medium including a program having stored instructions executable by a processor to:

allow a plan sponsor to define a first defined set of the fund use rules in order to define and make electronic payment directly to a first part of a non-carrier claim category portion of an electronically transmitted claim, according to control rights and ranking provided first to the plan sponsor for establishing a first tier of the hierarchy for electronic payment of the first part of the non-carrier claim category portion, from between two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan sponsor ranking, indicating a numerical ranking, between the two or more different accounts;

allow a plan sponsor to define a second defined set of the fund use rules in order to define and make electronic payment directly to a second part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided first to the plan sponsor for establishing a second tier of the hierarchy for electronic payment of the second part of the non-carrier claim category portion, from between two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan sponsor ranking, indicating a numerical ranking, between the at least two different accounts;

allow a plan member to define a third defined set of the fund use rules in order to define and make electronic payment directly to a remaining amount of the first part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided second to the plan member as part of the first tier of the hierarchy for further electronic payment of the first part of the non-carrier claim category portion, from between the two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan member ranking, indicating a numerical ranking, between the two or more different accounts;

allow a plan member to define a fourth defined set of the fund use rules in order to define and make electronic payment directly to a remaining amount of the second part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided second to the plan member as part of the second tier of the hierarchy for further electronic payment of the second part of the non-carrier claim category portion, from between the two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan member ranking, indicating a numerical ranking, between the two or more different accounts;

receive the electronically transmitted claim;

apply the plan sponsor ranking and the plan member ranking automatically between the two or more accounts to make payment on the first part of the electronically transmitted claim based on the first tier of the hierarchy; and

apply the plan sponsor ranking and the plan member ranking automatically between the two or more accounts to make payment on the second part of the electronically transmitted claim based on the second tier of the hierarchy.

14. The medium of claim 13, wherein defining a number of plan sponsor rules includes selecting a payment relationship between a plan sponsor and a plan member for handling a deductible payment associated with a particular claim type under the health insurance plan.

15. The medium of claim 13, wherein defining a number of plan sponsor rules includes selecting a payment relationship between a plan sponsor and a plan member for handling a co-payment associated with a particular claim type under the health insurance plan.

16. The medium of claim 13, wherein defining a number of plan sponsor rules includes selecting a payment relationship between a plan sponsor and a plan member for handling a coinsurance payment associated with a particular claim type under the health insurance plan.

17. The medium of claim 13, wherein defining a number of plan sponsor rules includes a plan sponsor selecting a hierarchy among a number of plan member health benefit accounts for application of funds to a particular claim type under the health insurance plan.

18. The medium of claim 17, wherein defining a number of member rules includes a plan member selecting a hierarchy among a number of plan member health benefit accounts for application of funds to a particular claim type under the health insurance plan secondary to the number of plan sponsor rules.

19. The medium of claim 13, wherein the method further includes tracking usage and available balances in a number of plan member health benefit accounts according to the number of plan sponsor rules and member rules.

20. A method for providing benefits, comprising:

utilizing a processor and a memory having computer readable instructions stored thereon that are executable on the processor for;

allowing, by a processor, a plan sponsor to define a first defined set of the fund use rules in order to define and make electronic payment directly to a first part of a non-carrier claim category portion of an electronically transmitted claim, according to control rights and ranking provided first to the plan sponsor for establishing a first tier of the hierarchy for electronic payment of the first part of the non-carrier claim category portion, from between two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan sponsor ranking, indicating a numerical ranking, between the two or more different accounts;

allowing, by a processor, a plan sponsor to define a second defined set of the fund use rules in order to define and make electronic payment directly to a second part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided first to the plan sponsor for establishing a second tier of the hierarchy for electronic payment of the second part of the non-carrier claim category portion, from between two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan sponsor ranking, indicating a numerical ranking, between the at least two different accounts;

allowing, by a processor, a plan member to define a third defined set of the fund use rules in order to define and make electronic payment directly to a remaining amount of the first part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided second to the plan member as part of the first tier of the hierarchy for further electronic payment of the first part of the non-carrier claim category portion, from between the two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan member ranking, indicating a numerical ranking, between the two or more different accounts;

allowing, by a processor, a plan member to define a fourth defined set of the fund use rules in order to define and make electronic payment directly to a remaining amount of the second part of the non-carrier claim category portion of the electronically transmitted claim, according to control rights and ranking provided second to the plan member as part of the second tier of the hierarchy for further electronic payment of the second part of the non-carrier claim category portion, from between the two or more different employee benefit accounts managed and administered by the plan sponsor, according to the plan member ranking, indicating a numerical ranking, between the two or more different accounts;

receiving the electronically transmitted claim;

applying the plan sponsor ranking and the plan member ranking automatically between the two or more accounts to make payment on the first part of the electronically transmitted claim based on the first tier of the hierarchy; and

applying the plan sponsor ranking and the plan member ranking automatically between the two or more accounts to make payment on the second part of the electronically transmitted claim based on the second tier of the hierarchy.