Liability insurer and health plan data exchange

• US 8,688,470 B1
• Filed: 02/22/2011
• Issued: 04/01/2014
• Est. Priority Date: 12/21/2010
• Status: Active Grant

• Current Assignee: Stephen Ambrose
• Original Assignee: ICEX, Inc.
• Inventors: Ambrose, Stephen
• Primary Examiner(s): Rangrej, Sheetal R
• Assistant Examiner(s): NGUYEN, TRANG T
• Application Number:
  US13/031,675
• Time in Patent Office: 1,134 Days
• Field of Search: 705/2, 705/3
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A data information exchange, which accesses data from liability insurers and health plans, manages the data and allows health plans to identify when their plan participants are third party claimants in injury claims. In another aspect, subrogation entities access the data information exchange in order to perform subrogation operations for the health plans, relating to the health plan'"'"'s participants. In another aspect, coordination of benefit recovery entities access the data information exchange in order to perform recovery operations for the health plans, relating to health providers which rendered services to participants of the health plans.

Claims

1. A system for an information exchange process comprising:

a hardware processor configured for;

i) performing processing associated with comparing health plan member data records to injured claimant data records from a liability insurer, utilizing a compare and match component of a computer-based information exchange system, the injured claimant data records stored in an information exchange database in communication with a processor, the injured claimant data records containing information about injured party claimants, the information comprising;

demographic data of the injured claimants, applicable legal representatives of the injured claimants, type of claim filed, date of loss or accident, or date of claim filing to the liability insurer, or any combination thereof, the injured claimant data records created by the liability insurer after receiving injury claims from injured party claimants, the health plan member data records not derived from medical claim data comprising treatment data, diagnosis date, or medication data, or any combination thereof, and containing identifying demographic information about members of health plans, the health plan member data records created by the health plans;

ii) performing processing associated with creating a matched data record by creating a query file from the health plan member data records used to query the injured claimant data records stored in the information exchange data base and transforming the query file and the injured claimant data records into a matched data record that identifies, utilizing the compare and match component of the computer-based information exchange system, a match of the identifying demographic information shared between injured claimant data records and the health plan member data records, the matched data record indicating individuals who are both injured party claimants and members of the health plan information about the injury claims relating to the members of the health plan, and the matched data record being stored in a matched records database; and

iii) performing processing associated with making available the matched data records so that information related to the filing of an actual injury claim is accessible to the health plan for purposes of health plan subrogation.

2. The system of claim 1, where the processor is further configured for performing processing associated with sending the matched data records to the health plans.

3. The system of claim 1, where the injured party claimants are represented by legal agents, the legal agents comprising:

i) an individual attorney;

ii) a legal firm;

iii) a legal association;

iv) public aid;

v) a mediation firm;

vi) a consultant;

vii) a parent;

or

viii) a legal guardian;

or

ix) any combination of the above.

4. The system of claim 1, where the liability insurer comprises coverage for the following lines of business:

i) personal

ii) commercial;

iii) specialty;

iv) reinsurance;

or

v) any line of business where received claims include medical billings received for injuries and treatment related to the claims;

or

vi) any combination of the above.

5. The system of claim 1, where health plans are health insurance coverage plans comprising:

i) Medicaid;

ii) self-insured health plans;

iii) group health plans;

iv) individual health plans;

v) county health plans;

vi) state health plans;

vii) federal health plans;

viii) private union health plans;

ix) workers compensation plans;

x) medical riders on, liability insurance plans;

or

xi) vendors of health plans;

or

xii) any combination of the above.

6. The system of claim 1, where injury claims are based upon circumstances, the circumstances comprising:

i) vehicular accident;

ii) work-related;

iii) premise liability;

iv) inadequate security;

v) construction site;

vi) amusement park;

vii) sexual misconduct;

viii) occupational disease;

ix) defective product;

x) pharmaceutical-related;

xi) birth injury;

xii) assault;

xiii) police brutality;

xiv) slip;

xv) fall;

xvi) negligence;

xvii) wrongful death;

xviii) medical malpractice;

or

xix) any causal circumstance which contributes, in part or whole, to an injury claim;

or

xx) any combination of the above.

7. The system of claim 1, where injured claimant data records are records comprising:

i) the first names of injured party claimants;

ii) the last names of injured party claimants;

iii) the birth dates of injured party claimants;

iv) the social security numbers of injured party claimants;

v) the home addresses of injured party claimants;

vi) the dates the injured party claimants filed their injury claims;

vii) the dates the liability insurers received the injury claims;

viii) the names of the attorneys representing the injured party claimants;

ix) the addresses of the attorneys representing the injured party claimants;

x) the phone numbers of the attorneys representing the injured party claimants;

xi) the fax numbers of the attorneys representing the injured party claimants;

or

xii) the mails of the attorneys representing the injured party claimants;

or

xiii) any combination of the above.

8. The system of claim 7, where social security numbers of injured party claimants comprise truncated portions of social security numbers.

9. The system of claim 1, where health plan member data records are records comprising:

i) the first names of members of health plans;

ii) the last names of members of health plans;

iii) the birth dates of members of health plans;

iv) the social security numbers of members of health plans;

or

v) the home addresses of members of health plans;

or

vi) any combination of the above.

10. The system of claim 9, where social security numbers of health plan members comprise truncated portions of social security numbers.

11. The system of claim 1, where health plan member data records comprise the names of the health plans.

12. The system of claim 1, where injury claims comprise lawsuits.

13. The system of claim 1, where the processor is further configured for performing processing associated with health plans making payments to the entity operating the information exchange process, in consideration and value for receiving matched data records.

14. The system of claim 13, where the processor is further configured for performing processing associated with paying a portion of collected health plan payments to liability insurers.

15. The system of claim 1, where the processor is further configured for performing processing associated with sending the matched data records to subrogation vendors.

16. The system of claim 1, where an entity that performs processing also performs subrogation operations on behalf of the health plans.

17. The system of claim 16, where the processor is further configured for performing processing associated with submitting subrogation claims against injury claim settlements of injured party claimants who are also health plan members, the subrogation claims submitted on behalf of the health plans.

18. The system of claim 16, where the processor is further configured for performing processing associated with calculating portions payable to the health plans after receiving subrogation payments out of injury claim settlements.

19. The system of claim 16, where the processor is further configured for performing processing associated with calculating portions payable to the computer-based information exchange after receiving subrogation payments from injury claim settlements.

20. The system of claim 16, where the processor is further configured for performing processing associated with calculating portions payable to liability insurers after receiving subrogation payments from injury claim settlements.

21. The system of claim 16, where the processor is further configured for performing processing associated with calculating the owed subrogation claim monies from injury claim settlements of health plan members who are also injured party claimants.

22. The system of claim 1, where the processor is further configured for performing processing associated with sending the matched data records to coordination of benefit recovery vendors.

23. The system of claim 1, where an entity that performs processing also performs coordination of benefit recovery operations on behalf of the health plans.

24. The system of claim 23, where the processor is further configured for performing processing associated with calculating owed coordination of benefit recovery claim monies.

25. The system of claim 23, where the processor is further configured for performing processing associated with recovering coordination of benefit monies on behalf of the health plans.

26. The system of claim 23, where the processor is further configured for performing processing associated with calculating portions of the recovered coordination of benefit monies payable to the health plans after receiving coordination of benefit recovery payments.

27. The system of claim 23, where the processor is further configured for performing processing associated with calculating portions payable to the computer-based information exchange after receiving coordination of benefit recovery payments.

28. The system of claim 23, where the processor is further configured for performing processing associated with calculating portions payable to liability insurers after receiving coordination of benefit recovery payments.

29. The system of claim 1, where the matched data reports identify liability insurers involved in the injury claims to the health plans which receive the reports.

30. The system of claim 1, where injured party claimants are third party claimants.

31. The system of claim 1, wherein the liability insurer provides coverage for casualty claims.

32. The system of claim 1, wherein the liability insurer provides coverage for workers compensation claims.

33. The system of claim 1, wherein the liability insurer provides coverage including:

i) product liability;

ii) general liability;

iii) public liability;

or

iv) professional liability;

or

v) any combination thereof.

34. A method for an information exchange process comprising:

i) performing processing associated with comparing health plan member data records to injured claimant data records from a liability insurer, utilizing a compare and match component of a computer-based information exchange system in communication with a processor circuit in communication with a database, the injured claimant data records stored in an information exchange database in communication with a processor, the injured claimant data records containing information about injured party claimants, the information comprising;

demographic data of the injured claimants, applicable legal representatives of the injured claimants, type of claim filed, date of loss or accident, or date of claim filing to the liability insurer, or any combination thereof, the injured claimant data records created by the liability insurer after receiving injury claims from injured party claimants, the health plan member data records not derived from medical claim data comprising treatment data, diagnosis data, or medication data, or any combination thereof, and containing identifying demographic information about members of health plans, the health plan member data records created by the health plans;

ii) performing processing associated with creating a matched data record by creating a query file from the health plan member data records used to query the injured claimant data records stored in the information exchange data base and transforming the query file and the injured claimant data records into a matched data record that identifies, utilizing the compare and match component of the computer-based information exchange system, a match of the identifying demographic information shared between injured claimant data records and the health plan member data records, the matched data record indicating individuals who are both injured party claimants and members of the health plan information about the injury claims relating to the members of the health plan, and the matched data record being stored in a matched records database; and

iii) performing processing associated with making available the matched data records so that information related to the filing of an actual injury claim is accessible to the health plan for purposes of health plan subrogation.

35. The method of claim 34, further comprising performing processing associated with sending the matched data records to the health plans.

36. The method of claim 34, wherein the injured party claimants are represented by legal agents, the legal agents comprising:

i) an individual attorney;

ii) a legal firm;

iii) a legal association;

iv) public aid;

v) a mediation firm;

vi) a consultant;

vii) a parent;

or

viii) a legal guardian;

or

ix) any combination of the above.

37. The method of claim 34, where a liability insurer is an insurer handling lines of business, the lines of business comprising:

i) personal

ii) commercial;

iii) specialty;

iv) reinsurance;

or

v) any line of business where received claims include medical billings received for injuries and treatment related to the claims;

or

vi) any combination of the above.

38. The method of claim 34, wherein health plans are health insurance coverage plans comprising:

i) Medicaid;

ii) self-insured health plans;

iii) group health plans;

iv) individual health plans;

v) county health plans;

vi) state health plans;

vii) federal health plans;

viii) private union health plans;

ix) workers compensation plans;

x) medical riders on liability insurance plans;

or

xi) vendors of health plans;

or

xii) any combination of the above.

39. The method of claim 34, where injury claims are based upon circumstances, the circumstances comprising:

i) vehicular accident;

ii) work-related;

iii) premise liability;

iv) inadequate security;

v) construction site;

vi) amusement park;

vii) sexual misconduct;

viii) occupational disease;

ix) defective product;

x) pharmaceutical-related;

xi) birth injury;

xii) assault;

xiii) police brutality;

xiv) slip;

xv) fall;

xvi) negligence;

xvii) wrongful death;

xviii) medical malpractice;

or

xix) any causal circumstance which contributes, in part or whole, to an injury claim;

or

xx) any combination of the above.

40. The method of claim 34, where injured claimant data records are records comprising:

i) the first names of injured party claimants;

ii) the last names of injured party claimants;

iii) the birth dates of injured party claimants;

iv) the social security numbers of injured party claimants;

v) the home addresses of injured party claimants;

vi) the dates the injured party claimants filed their injury claims;

vii) the dates the liability insurer received the injury claims;

viii) the names of the attorneys representing the injured party claimants;

ix) the addresses of the attorneys representing the injured party claimants;

x) the phone numbers of the attorneys representing the injured party claimants;

xi) the fax numbers of the attorneys representing the injured party claimants;

or

xii) the entails of the attorneys representing the injured party claimants;

or

xiii) any combination of the above.

41. The method of claim 34, where health plan member data records are records comprising:

i) the first names of members of health plans;

ii) the last names of members of health plans;

iii) the birth dates of members of health plans;

iv) the social security numbers of members of health plans;

or

v) the home addresses of members of health plans;

or

vi) any combination of the above.

42. The method of claim 41, where social security numbers of injured party claimants comprise truncated portions of social security numbers.

43. The method of claim 41, where social security numbers of health plan members comprise truncated portions of social security numbers.

44. The method of claim 34, where health plan member data records comprise the names of the health plans.

45. The method of claim 34, where injury claims comprise lawsuits.

46. The method of claim 34, further comprising performing processing associated with health plans making payments to the entity operating the information exchange process, in consideration and value for receiving matched data records.

47. The method of claim 46, further comprising performing processing associated with paying a portion of collected health plan payments to liability insurers.

48. The method of claim 34, further comprising performing processing associated with sending the matched data records to subrogation vendors.

49. The method of claim 34, wherein an entity that performs processing also performs subrogation operations on behalf of the health plans.

50. The method of claim 49, further comprising performing processing associated with calculating the owed subrogation claim monies from injury claim settlements of health plan members who are also injured party claimants.

51. The method of claim 34, further comprising performing processing associated with sending the matched data records to coordination of benefit recovery vendors.

52. The method of claim 34, where an entity that performs processing also performs coordination of benefit recovery operations on behalf of the health plans.

53. The method of claim 52, further comprising performing processing associated with calculating owed coordination of benefit recovery claim monies.

54. The method of claim 52, further comprising performing processing associated with recovering coordination of benefit monies on behalf of the health plans.

55. The method of claim 52, further comprising performing processing associated with calculating portions of the recovered coordination of benefit monies payable to the health plans after receiving coordination of benefit recovery payments.

56. The method of claim 52, further comprising performing processing associated with calculating portions payable to the computer-based information exchange after receiving coordination of benefit recovery payments.

57. The method of claim 52, further comprising performing processing associated with calculating portions payable to liability insurers after receiving coordination of benefit recovery payments.

58. The method of claim 49, further comprising performing processing associated with submitting subrogation claims against injury claim settlements of injured party claimants who are also health plan members, the subrogation claims submitted on behalf of the health plans.

59. The method of claim 49, further comprising performing processing associated with calculating portions payable to the health plans after receiving subrogation payments out of injury claim settlements.

60. The method of claim 49, further comprising performing processing associated with calculating portions payable to the computer-based information exchange after receiving subrogation payments from injury claim settlements.

61. The method of claim 49, further comprising performing processing associated with calculating portions payable to liability insurers after receiving subrogation payments from injury claim settlements.

62. The method of claim 34, where the matched data reports identify liability insurers involved in the injury claims to the health plans which receive the reports.

63. The method of claim 34, where injured party claimants are third party claimants.

64. The method of claim 34, wherein the liability insurer provides coverage for casualty claims.

65. The method of claim 34, wherein the liability insurer provides coverage for workers compensation claims.

66. The method of claim 34, wherein the liability insurer provides coverage including:

i) product liability;

ii) general liability;

iii) public liability;

or

iv) professional liability;

or

v) any combination thereof.