Method, system and computer program product for generating an electronic bill having optimized insurance claim items

• US 8,560,350 B2
• Filed: 11/22/2005
• Issued: 10/15/2013
• Est. Priority Date: 11/22/2005
• Status: Active Grant

• Current Assignee: Robert J. Nadai
• Original Assignee: Robert J. Nadai
• Inventors: Nadai, Robert J.
• Primary Examiner(s): KANERVO, VIRPI H
• Application Number:
  US11/285,579
• Publication Number:
  US 20070118410A1
• Time in Patent Office: 2,884 Days
• Field of Search: None
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

A method, system and computer program product for generating an electronic bill having optimized insurance claim items based on an insurance carrier of a patient are provided. The method includes receiving insurance carrier data which identifies a patient'"'"'s insurance carrier and patient data which identifies a patient. The method also includes receiving treatment data which identifies a drug administered to the patient and a procedure performed on the patient on a date of service. The treatment data is processed to obtain nurse documentation, such as treatment and/or flow sheets. An electronic bill is automatically generated having optimized reimbursable insurance claim items including predetermined codes based on the treatment data and the insurance carrier data to facilitate approval of the bill by the insurance carrier.

Claims

1. A computerized method for generating an electronic bill having optimized insurance claim items based on an insurance carrier of a patient, the method comprising:

receiving via a user interface insurance carrier data which identifies a patient'"'"'s insurance carrier and patient data which identifies a patient;

receiving via the user interface treatment data which identifies at least one drug including a chemotherapy drug administered to the patient and at least one type of administration used to administer the at least one drug to the patient on a date of service;

displaying via the user interface a prompt offering to bill an additional expense item eligible for reimbursement based on a comparison between the treatment data and eligible coverage defined by the insurance carrier identified by the insurance carrier data;

receiving via the user interface a signal which represents user acceptance of the offering to bill the additional expense item;

processing the treatment data by a computing device to obtain nurse documentation, including at least one of;

treatment sheet, flow sheet, drug inventory form, and reorder form; and

automatically generating by the computing device the electronic bill having optimized reimbursable insurance claim items including the additional expense item in response to the signal, the claim items having predetermined codes based on the treatment data and the insurance carrier data to facilitate approval of the bill and to maximize reimbursement by the insurance carrier.

2. The method as claimed in claim 1, wherein the treatment data also identifies at least one of:

a drug dosage, time spent in administering the drug, and supplies used in administering the drug.

3. The method as claimed in claim 1, wherein the treatment sheet includes at least one of:

a route taken to administer the drug, names of drugs in same concurrent infusion, and time spent to administer the drug.

4. The method as claimed in claim 1, further comprising applying an appropriate modifier to at least one claim item on the bill.

5. The method as claimed in claim 1, further comprising adding at least one predetermined code required for reimbursement of the drug or procedure.

6. The method as claimed in claim 1, further comprising verifying that an HCT level is recorded and meets a minimum level required for reimbursement of the drug by the insurance carrier.

7. The method as claimed in claim 1, further comprising generating remarks containing at least one of:

a predetermined code, a drug name, a drug dosage, a drug waste, and a route taken in administering the drug.

8. The method as claimed in claim 1, further comprising generating remarks to document when the patient provides the administered drug to ensure reimbursement for administration of the patient-provided drug.

9. The method as claimed in claim 1, further comprising issuing an appropriate code for the administration of the at least one drug.

10. The method as claimed in claim 1, further comprising applying a predetermined code to distinguish between types of administrations and any concurrent infusions.

11. The method as claimed in claim 1, further comprising determining a correct set of codes and respective quantity fields to bill a correct representation of infusion times and drug quantities, including waste and administration counts.

12. The method as claimed in claim 1, further comprising disallowing multiple drug administrations unless a predetermined code is included on the bill.

13. The method as claimed in claim 12, further comprising generating a claim item with an associated predetermined code wherein a total dosage of the drug is substantially equal to a sum of the dosages of multiple drugs.

14. The method as claimed in claim 1, further comprising ordering and sequencing the claim items of claims in a manner to facilitate approval of the bill by the insurance carrier.

15. The method as claimed in claim 14, wherein related administered drugs and their respective predetermined codes are grouped together in a single claim.

16. The method as claimed in claim 1, further comprising issuing prompts for supplies by the insurance carrier, issuing prompts for office visits, and tracking of chemo follow-up visits.

17. The method as claimed in claim 1, further comprising precisely estimating drug waste.

18. The method as claimed in claim 1, further comprising collecting and generating documentation in the treatment sheet to corroborate a claim.

19. The method as claimed in claim 1, further comprising monitoring and issuing alerts pertaining to elapsed infusion times, supplies, drug package and vial sizes, and other services.

20. The method as claimed in claim 1, further comprising generating various reports with application of different fee schedules and usage of drugs by package and vial sizes.

21. The method as claimed in claim 1, further comprising generating various fee schedules to accommodate data entry into a billing software system and to facilitate financial analysis of patient encounters.

22. The method as claimed in claim 1, further comprising tracking of drug usage in order to maintain inventory and to activate ordering of drugs for practice.

23. A system for generating an electronic bill having optimized insurance claim items based on an insurance carrier of a patient, the system comprising:

a processor configured to execute computer program instructions;

a memory configured to store the computer program instructions executable by the processor; and

the computer program instructions stored in the memory to perform the steps of;

receiving via a user interface insurance carrier data which identifies a patient'"'"'s insurance carrier and patient data which identifies a patient;

receiving via the user interface treatment data which identifies at least one drug including a chemotherapy drug administered to the patient and at least one type of administration used to administer the at least one drug to the patient on a date of service;

displaying via the user interface a prompt offering to bill an additional expense item eligible for reimbursement based on a comparison between the treatment data and eligible coverage defined by the insurance carrier identified by the insurance carrier data;

receiving via the user interface a signal which represents user acceptance of the offering to bill the additional expense item;

processing the treatment data to obtain nurse documentation, including at least one of;

treatment sheet, flow sheet, drug inventory form, and reorder form; and

automatically generating the electronic bill having optimized reimbursable insurance claim items including the additional expense item in response to the signal, the claim items having predetermined codes based on the treatment data and the insurance carrier data to facilitate approval of the bill and to maximize reimbursement by the insurance carrier.

24. The system as claimed in claim 23, wherein the treatment data also identifies at least one of:

a drug dosage, time spent in administering the drug, and supplies used in administering the drug.

25. The system as claimed in claim 23, wherein the treatment sheet includes at least one of:

a route taken to administer the drug, names of the drugs in the same concurrent infusion, and time spent to administer the drug.

26. The system as claimed in claim 23, wherein the instructions perform the step of applying an appropriate modifier to at least one claim item on the bill.

27. The system as claimed in claim 23, wherein the instructions perform the step of adding at least one predetermined code required for reimbursement of the drug or procedure.

28. The system as claimed in claim 23, wherein the instructions perform the step of verifying that an HCT level is recorded and meets a minimum level required for reimbursement of the drug by the insurance carrier.

29. The system as claimed in claim 23, wherein the instructions perform the step of generating remarks containing at least one of:

a predetermined code, a drug name, a drug dosage, a drug waste, and a route taken in administering the drug.

30. The system as claimed in claim 23, wherein the instructions perform the step of generating remarks to document when the patient provides the administered drug to ensure reimbursement for administration of the patient-provided drug.

31. The system as claimed in claim 23, wherein the instructions perform the step of issuing an appropriate code for the administration of the at least one drug.

32. The system as claimed in claim 23, wherein the instructions perform the step of applying a predetermined code to distinguish between types of administrations and any concurrent infusions.

33. The system as claimed in claim 23, wherein the instructions perform the step of determining a correct set of codes and respective quantity fields to bill a correct representation of infusion times and drug quantities, including waste and administration counts.

34. The system as claimed in claim 23, wherein the instructions perform the step of disallowing multiple drug administrations unless a predetermined code is included on the bill.

35. The system as claimed in claim 34, wherein the instructions perform the step of generating a claim item with an associated predetermined code wherein a total dosage of the drug is substantially equal to a sum of dosages of multiple drugs.

36. The system as claimed in claim 23, wherein the instructions perform the step of ordering and sequencing the claim items of claims in a manner to facilitate approval of the bill by the insurance carrier.

37. The system as claimed in claim 36, wherein related administered drugs and their respective predetermined codes are grouped together by the instructions in a single claim.

38. The system as claimed in claim 23, wherein the instructions perform the steps of issuing prompts for supplies by the insurance carrier, issuing prompts for office visits, and tracking of chemo follow-up visits.

39. The system as claimed in claim 23, wherein the instructions perform the step of precisely estimating drug waste.

40. The system as claimed in claim 23, wherein the instructions perform the step of collecting and generating documentation in the treatment sheet to corroborate a claim.

41. The system as claimed in claim 23, wherein the instructions perform the steps of monitoring and issuing alerts pertaining to elapsed infusion times, supplies, drug package sizes, vial sizes, and other services.

42. The system as claimed in claim 23, wherein the instructions perform the step of generating various reports with application of different fee schedules and usage of drugs by package and vial sizes.

43. A computer readable non-transitory medium that when executed by a processor causes a computer to perform the steps of:

receiving via a user interface insurance carrier data which identifies a patient'"'"'s insurance carrier and patient data which identifies a patient;

receiving via the user interface treatment data which identifies at least one drug including a chemotherapy drug administered to the patient and at least one type of administration used to administer the at least one drug to the patient on a date of service;

displaying via the user interface a prompt offering to bill an additional expense item eligible for reimbursement based on a comparison between the treatment data and eligible coverage defined by the insurance carrier identified by the insurance carrier data;

receiving via the user interface a signal which represents user acceptance of the offering to bill the additional expense item;

processing the treatment data to obtain nurse documentation, including at least one of;

treatment sheet, flow sheet, drug inventory form, and reorder form; and

automatically generating the electronic bill having optimized reimbursable insurance claim items including the additional expense item in response to the signal, the claim items having predetermined codes based on the treatment data and the insurance carrier data to facilitate approval of the bill and to maximize reimbursement by the insurance carrier.

44. The computer readable non-transitory medium as claimed in claim 43, wherein the step of automatically generating is performed at least in part via a computing device.