Direct connectivity system for healthcare administrative transactions

• US 9,020,826 B2
• Filed: 06/27/2005
• Issued: 04/28/2015
• Est. Priority Date: 06/28/2004
• Status: Active Grant

• Current Assignee: Accenture Global Services Limited (Accenture PLC)
• Original Assignee: Accenture Global Services Limited (Accenture PLC)
• Inventors: Marvin, William F., Seib, Christopher D.
• Primary Examiner(s): Niquette, Robert R
• Application Number:
  US11/167,548
• Publication Number:
  US 20050288972A1
• Time in Patent Office: 3,592 Days
• Field of Search: None
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/14 specially adapted for billing systems
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• 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

Abstract

A direct connectivity system provides automated healthcare administrative transaction submission, including claim submission, eligibility verification and claim status, from healthcare service providers directly to payers. The direct connectivity system bypasses transaction processing intermediaries such as clearinghouses by directly connecting providers to payers in a many to many manner. Existing single payer web portals are supplanted by a many to many network that has a common interface across multiple payers. The direct connectivity system may receive responses directly from payers and may prepare or process the responses for a practice management program so that the service provider receives rapid feedback on the administrative transaction submission. The direct connectivity system may automatically analyze transaction file attributes to determine one or more of many payers to which to send a transaction file, from one of many providers. Batch and singleton file transfer is supported for multiple file formats, optionally with secure file transfer.

Claims

1. A non-transitory machine readable medium encoded with instructions that cause a service provider data processing system to perform a method comprising the acts of:

determining that an administrative transaction file has been prepared by a practice management program, wherein the administrative transaction file includes a predetermined file attribute specified by administrative transaction file configuration data that includes a plurality of predetermined file attributes associated with payer identification information for multiple payers;

determining, using the predetermined file attribute of the transaction file, payer identification information for a selected payer associated with the transaction file from the payer identification information for multiple payers;

determining, using the payer identification information for the selected payer, payer communication data for the selected payer;

initiating transmission of the transaction file from a hardware implemented direct connectivity gateway to the selected payer of the multiple payers using the determined payer communication data, thereby bypassing transaction file processing intermediaries;

receiving, at the hardware implemented direct connectivity gateway, a response from the selected payer to the transmission of the transaction file; and

configuring the response for the practice management program by modifying attributes of the response for automated processing by the practice management program.

2. The machine readable medium of claim 1, where the predetermined file attribute is a filename.

3. The machine readable medium of claim 1, where the predetermined file attribute is a file directory.

4. The non-transitory machine readable medium of claim 1, further comprising applying extensible markup language tags to all or part of the transaction file.

5. The non-transitory machine readable medium of claim 1, wherein the modified attributes of the response include a filename or a directory name.

6. The non-transitory machine readable medium of claim 1, wherein the modified attributes of the response include a format of the response.

7. The machine readable medium of claim 1, wherein the response is based on a determination by the selected payer of whether an amount associated with a claim associated with the administrative transaction file is between specified limits.

8. A non-transitory machine readable medium encoded with instructions that cause a hardware implemented direct connectivity gateway to perform a method comprising the acts of:

connecting to a service provider data processing system through a communication interface;

determining that a transaction file has been prepared on the service provider data processing system by a claim management program;

transferring the transaction file to the hardware implemented direct connectivity gateway;

obtaining a selected file attribute of the transaction file;

reading payer connection data to determine a selected payer of multiple payers for the transaction file according to attribute data that associates file attributes, including the selected file attribute, with the multiple payers, including the selected payer, wherein the selected file attribute is a predetermined file attribute specified by administrative transaction file configuration data that includes a plurality of the file attributes associated with payer identification information for the multiple payers;

initiating transmission of the transaction file from the hardware implemented direct connectivity gateway to the selected payer of the multiple payers, thereby bypassing transaction file processing intermediaries;

receiving, at the hardware implemented direct connectivity gateway, a response from the selected payer to the transmission of the transaction file; and

configuring the response for the claim management program by modifying attributes of the response for automated processing by the claim management program.

9. The machine readable medium of claim 8, where the act of connecting to the service provider data processing system comprises the act of connecting to a service provider data processing system co-located with the hardware implemented direct connectivity gateway.

10. The machine readable medium of claim 8, where the predetermined file attribute is a filename.

11. The machine readable medium of claim 8, where the predetermined file attribute is a file directory.

12. The machine readable medium of claim 8, wherein reading payer connection data to determine a selected payer for the transaction file according to attribute data that associates transaction file attributes, including the selected file attribute, with multiple payers, including the selected payer comprises:

determining, using the selected file attribute of the transaction file, the payer identification information for the selected payer from the multiple payers; and

determining, using the payer identification information for the selected payer, the payer connection data for the selected payer.

13. The machine readable medium of claim 8, wherein initiating transmission of the transaction file to the selected payer of the multiple payers, thereby bypassing transaction file processing intermediaries comprises:

initiating the transmission of the transaction file to the selected payer using the payer connection data.

14. A system operable to provide connectivity to a payer computer system, the system comprising:

a processor; and

data storage storing claims configuration information for multiple payers, the claims configuration information including, for each payer, payer identification information, a file attribute, and payer communication data,

wherein the processor

determines a transaction file has been prepared by a practice management program, wherein the administrative transaction file is created using the claims configuration information,

determines a selected file attribute of the transaction file, wherein the selected file attribute is one of the file attributes in the claims configuration information,

determines, using the selected file attribute of the transaction file, the payer identification information corresponding to the selected file attribute from the claims configuration information;

determines, using the payer identification information, the payer communication data corresponding to the payer identification information from the claims configuration information,

initiates transmission of the transaction file from a hardware implemented direct connectivity interface to a payer identified by the payer identification information using the determined payer communication data, thereby bypassing transaction file processing intermediaries,

receives, at the hardware implemented direct connectivity interface, a response from the selected payer to the transmission of the transaction file, and

configures the response for the practice management program by modifying attributes of the response for automated processing by the practice management program.

15. The system of claim 14, wherein the selected file attribute comprises at least one of a filename and a file directory.