Medical of increasing efficiency in a medical claim transaction, and computer program capable of executing same

• US 8,738,402 B2
• Filed: 02/06/2013
• Issued: 05/27/2014
• Est. Priority Date: 01/21/2000
• Status: Expired due to Fees

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: TriZetto Corporation (Cognizant Technology Solutions Corp.)
• Inventors: Chapman, Sherwood, Echeverria, J. Mikel
• Primary Examiner(s): Fuelling, Michael
• Application Number:
  US13/760,318
• Publication Number:
  US 20130151282A1
• Time in Patent Office: 475 Days
• Field of Search: 705 2- 4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Claims

1. A method of adjudicating a medical claim, the method comprising:

storing a plurality of medical claims on a claim processing server accessible over the Internet by a medical service provider, each medical claim representing medical benefits and having a set of requirements;

receiving over the Internet a medical claim request from the medical service provider and storing the medical claim request on the claim processing server, the medical claim request comprising a plurality of components that includes identification of a proposed medical procedure that is to be performed on a patient;

setting by a computer program running on the claim processing server an initial score for at least some of the medical claims;

adjusting by a computer program running on the claim processing server at least some of the initial scores in one of a positive direction or negative direction by evaluating at least some of the components of the medical claim request against at least some of the requirements for at least some of the medical claims and determining whether a component of the medical claim request matches a requirement, thereby producing a plurality of adjusted scores for at least some of the medical claims;

selecting by a computer program running on the claim processing server a medical claim based on the plurality of adjusted scores;

adjudicating by a computer program running on the claim processing server the medical claim request by determining acceptance or rejection of the medical claim request and a monetary value of a proposed medical procedure according to the adjusted score of the selected medical claim;

transmitting by the claim processing server a notification over the Internet to the medical service provider, the notification comprising one of (a) a rejection of the proposed medical procedure, and (b) an acceptance of the proposed medical procedure with the monetary value.

2. The method of claim 1, wherein the monetary value is an amount to be paid by a medical plan provider to the medical service provider.

3. The method of claim 1, wherein the monetary value is one of an amount of insurance and a medical coverage provided by a medical plan provider to the patient.

4. The method of claim 1, wherein the monetary value is an amount that the patient owes to medical service provider.

5. The method of claim 1, further comprising the claim processing server processing the medical claim request as a transaction in real-time.

6. The method of claim 1, further comprising the medical service provider receiving the notification before the medical procedure is provided to the patient.

7. The method of claim 1, wherein the notification comprises the rejection and includes an explanation of why the medical claim request was rejected.

8. The method of claim 7, further comprising allowing the medical service provider to interactively re-submit an alteration of the medical claim request.

9. The method of claim 1, further comprising the claim processing server comparing the medical claim request to a medical history of the patient to determine if the medical claim request is rejected as a duplicative medical claim.

10. The method of claim 9, further comprising the claim processing server accepting the duplicative medical claim if the proposed medical procedure is to be performed at a different time from a previous, similar medical procedure.

11. The method of claim 1, wherein the step of selecting a medical claim includes selecting a first medical claim over a second medical claim based on their respective adjusted scores when the first and the second medical claims have overlapping requirements.

12. The method of claim 1, wherein the set of requirements include optional conditions.

13. The method of claim 12, wherein the step of evaluating the components of the medical claim request includes setting the score based on the components matching the optional conditions.

14. The method of claim 1 , wherein the step of transmitting the notification includes sending the notification in a secure health exchange envelope.

15. The method of claim 1, wherein the medical claim request comprises a pre-approval request.

16. The method of claim 1, wherein the proposed medical procedure comprises a referral to a specialist.

17. The method of claim 1, further comprising the step of providing access to the claim processing server to a medical plan provider.

18. The method of claim 1, further comprising comparing the proposed medical procedure to benefits of the patient'"'"'s medical plans to determine under which plan the medical claim should be processed.

19. The method of claim 18, further comprising the step of the server substituting a substituted medical procedure for the proposed medical procedure in the medical claim request before adjudicating the medical claim request.

20. The method of claim 19, wherein the notification includes acceptance of the substituted medical procedure as a covered procedure.