System and method for processing payment bundles

• US 8,756,075 B1
• Filed: 05/18/2011
• Issued: 06/17/2014
• Est. Priority Date: 05/18/2011
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: TriZetto Corporation (Cognizant Technology Solutions Corp.)
• Inventors: Hoerle, Dale, Sultan, Jay, Downs, Howard
• Primary Examiner(s): Chng, Joy
• Application Number:
  US13/110,182
• Time in Patent Office: 1,126 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 20/00 Payment architectures, schemes or protocols apparatus for performing or posting payment transactions G07F7/08, G07F19/00; electronic cash registers G07G1/12
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.

Claims

1. A process for repricing individual provider claims comprising:

receiving, at a processing system including at least one server, from a payer a first data set including first specific data from a first individual provider claim;

analyzing, by the processing system including at least one server, the first data set to determine one of the following;

(a) the first individual provider claim is part of an existing payment bundle;

(b) the first individual provider claim triggers creation of a patient event and an associated payment bundle;

(c) the first individual provider claim is neither (a) or (b);

(d) the first individual provider claim should be held up to a predetermined amount of time pending receipt by the processing system of additional data or passage of the predetermined amount of time; and

transmitting to the payer, by the processing system including at least one server, at least one of the following responses in accordance with the analysis;

(e) the first individual provider claim is not part of an existing or associated payment bundle, pay the provider under non-payment bundle terms;

(f) the first individual provider claim is part of an existing or associated payment bundle, pay the provider under one of existing or associated payment bundle terms;

(g) the first individual provider claim did not contain enough information, delay payment to the provider;

receiving by the processing system including at least one server, bundle type definitions and bundle-specific rules associated with each bundle type definition;

formulating payment bundles using the bundle type definitions and the bundle-specific rules; and

storing payment bundles in at least a first database of the processing system.

2. The process according to claim 1, wherein the response in accordance with (g) to delay payment further includes one of:

(g)(i) delay payment to the provider for up to a predetermined amount of time; and

(g)(ii) delay payment to the provider until receipt of additional instructions.

3. The process according to claim 1, wherein the analyzing in accordance with one of (a) through (d) includes analysis of the first data set and one or more previously received data sets.

4. The process according to claim 1, wherein if (a) is determined, the processing system:

reprices an amount to be paid to the provider in accordance with pre-established rules defining the existing payment bundle; and

reports the repriced amount to be paid on the first individual provider claim in accordance with (f).

5. The process according to claim 4, further comprising including reporting an explanation code with the repriced amount indicating to the payer why an amount was repriced.

6. The process according to claim 4, further comprising after repricing the first individual provider claim and reporting to the payer in accordance with (f):

receiving, at a processing system, at least one of a second data set including second specific data from a different individual provider claim and non-claim information;

determining, at a processing system, based on the received second data set that the first individual claim should no longer be included in the existing payment bundle;

repricing, at a processing system, the first individual claim in accordance with the determination; and

reporting, by a processing system, a result of the repricing to the payer.

7. The process according to claim 1, wherein if (b) is determined, the processing system:

reprices an amount to be paid to the provider in accordance with pre-established rules defining the associated payment bundle;

searches at least a first database of the processing system to identify any previously received individual provider claims that are included in the associated payment bundle;

reprices an amount that should have been paid to a provider of each identified previously received individual provider claims in accordance with pre-established rules defining the associated payment bundle; and

reports the repriced amount to be paid on the first individual provider claim and any repriced amounts that should have been paid to providers of each identified previously received individual provider claims in the associated payment bundle.

8. The process according to claim 1, wherein if (c) is determined, the processing system reports to the payer that the first individual provider claim is not subject to repricing.

9. The process according to claim 1, wherein if (d) is determined, the processing system:

holds the first individual provider claim data for up to the predetermined amount of time;

compares a combination of the first individual provider claim data and additional data received by the processing system during the predetermined amount of time but after the first individual provider claim was received to one or more definitions for the existing payment bundle and the associated payment bundle;

if the comparison results in a determination that the first individual provider claim is part of an existing payment bundle or triggers creation of a patient event and an associated payment bundle, the processing system;

reprices an amount to be paid to the provider in accordance with pre-established rules defining the existing or associated payment bundle; and

reports the repriced amount to be paid on the first individual provider claim in accordance with (f);

whereas, if the comparison results in a determination that the first individual provider claim is not part of an existing or associated payment bundle, the processing system reports to the payer that the first individual provider claim is not subject to repricing.

10. The process according to claim 1, wherein if (d) is determined, the processing system:

holds the first individual provider claim data until receipt by the processing system of the additional data;

compares a combination of the first individual provider claim data and the additional data received by the processing system after the first individual provider claim was received to one or more definitions for the existing payment bundle and the associated payment bundle;

if the comparison results in a determination that the first individual provider claim is part of an existing payment bundle or triggers creation of a patient event and an associated payment bundle, the processing system;

reprices an amount to be paid to the provider in accordance with pre-established rules defining the existing or associated payment bundle; and

reports the repriced amount to be paid on the first individual provider claim in accordance with (f);

whereas, if the comparison results in a determination that the first individual provider claim is not part of an existing or associated payment bundle, the processing system reports to the payer that the first individual provider claim is not subject to repricing.

11. The process according to claim 1, further comprising:

transmitting the payment bundles to the payer for storage on a payer database.

12. The process according to claim 1, wherein analyzing the data set includes comparison of at least patient identification (ID) and date of individual provider claim with an existing payment bundle definition.

13. The process according to claim 1, wherein pay under non-payment bundle terms is fee-for-service.

14. The process according to claim 1, wherein payment in accordance with (f) under existing or associate payment bundle terms is zero for all individual provider claims with the exception of a payment trigger individual provider claim.

15. The process according to claim 1, wherein receiving a data set including specific data from an individual provider claim occurs during adjudication of the individual provider claim and before payer pays the individual provider.

16. The process according to claim 1, wherein response (f) includes instructions for unbundling a payment under the payment bundle to distribute the payment to each individual provider providing services under the payment bundle.

17. The process according to claim 1, further comprising after transmitting to the payer at least one of the responses:

receiving, at a processing system, at least one of a second data set including second specific data from a different individual provider claim and non-claim information that changes one of (a) through (g) with respect to the first individual claim provider claim;

reporting the change to the payer.

18. The process according to claim 1, further comprising after repricing the first individual provider claim and reporting to the payer in accordance with (f):

receiving, at a processing system, at least one of a second data set including second specific data from a different individual provider claim and non-claim information;

determining, at a processing system, based on the received second data set that at least one of the first individual provider claim and each identified previously received individual provider claims should no longer be included in the associated payment bundle;

repricing, at a processing system, the at least one of the first individual claim and each identified previously received individual provider claims in accordance with the determination; and

reporting, by a processing system, a result of the repricing to the payer.