Claim processing validation system

• US 9,721,315 B2
• Filed: 06/16/2008
• Issued: 08/01/2017
• Est. Priority Date: 07/13/2007
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Christen, James D.
• Primary Examiner(s): Ng, Jonathan K
• Application Number:
  US12/139,556
• Publication Number:
  US 20090018866A1
• Time in Patent Office: 3,333 Days
• CPC Class Codes: G06Q 10/10 Office automation; Time management

Abstract

A system evaluates processing rules used for processing claim data related to reimbursement for provision of healthcare to a patient by specific payer organizations. The system includes at least one repository of information including first claim data. The first claim data processing rules and associated output data comprise first claim result information derived by applying the first claim data processing rules to the first claim data. The system also includes a source of a second claim data processing rule and a rules processor for applying the second claim data processing rule to the first claim data in deriving second claim result information corresponding to the first claim result information. A comparator compares the second claim result information with the first claim result information to identify changed result data elements and associated data fields in a claim form used in obtaining reimbursement in response to a claim. An output processor provides data representing a visual display image highlighting data fields associated with the changed result data elements.

Claims

1. A system including at least one hardware processing device for simulating and validating integrated system performance for changes to processing rules used for processing a claim form and data related to reimbursement for provision of healthcare to a patient by specific payer organizations, comprising:

at least one repository of information including;

a validation claim data group comprising a plurality of claims previously processed in a non-simulated healthcare reimbursement system, a validation set of claim data processing rules, wherein said validation set of claim data processing rules represents a version of claim data processing rules used in said non-simulated healthcare reimbursement system for processing healthcare reimbursement claims, and

a validation output data set comprising validation claim result data derived from processing said plurality of claims of said validation claim data group according to said validation set of claim data processing rules, said validation output data set comprising a validation processing time duration corresponding to a processing time required to process said plurality of claims data;

a set of modified claim data processing rules comprising one or more changes to a code for claim data processing rules for use in said non-simulated healthcare reimbursement system, said set of modified claim data processing rules including at least one claim data processing rule that is different from at least one claim data processing rule of said validation set of claim data processing rules;

a rules processor, in a simulated healthcare reimbursement system, for;

processing said plurality of claims of said validation claim data group according to said set of modified claim data processing rules and generating modified claim result data;

based on the modified claim result data, generating a modified output data set, said modified output data set comprising;

a modified processing time duration corresponding to a processing time required to process said plurality of modified claims according to said set of modified claim data processing rules data, said modified processing time duration being stored in said at least one repository of information for evaluation of claim processing throughput;

a comparator for validating said set of modified claim data processing rules, said comparator being configured to;

compare said modified output data set with said validation output data set to identify changed claim data elements between said validation output data set and said modified output data set; and

determine a change in rules processing duration by comparing said modified processing time duration to said validation processing time duration; and

an output processor for providing a validated output form that includes an indication of said change in rules processing duration and said changed claim data elements, and storing said validated output form in a validated output form directory.

2. A system according to claim 1, wherein said output processor provides data representing an electronic transaction message highlighting data fields associated with said changed data elements.

3. A system according to claim 1, wherein said at least one repository of information includes a plurality of sets of validation claim data groups and includes a user interface enabling a user to select said validation claim data group from said plurality of sets of validation claim data groups.

4. A system according to claim 1, including a trace processor for providing data representing a trace of execution of rules including said modified claim data processing rules applied in processing said validation claim data group and for verifying that said modified claim data processing rules have been executed.

5. A system according to claim 1, wherein said validation claim data group is in Extensible Markup Language (XML) compatible format and including a transformation processor for converting claim data to said validation claim data group in XML format.

6. A system according to claim 1, wherein said validation claim data processing rules comprise payer organization rules.

7. A system according to claim 6, wherein said payer organization rules include at least one of, (a) payer organization specific rules and (b) payer organization customized rules.

8. A system according to claim 1, wherein said modified claim data processing rules comprise payer organization rules derived from rule information provided by a regulatory authority associated with setting reimbursement rates for treatment services.

9. A system according to claim 1, including a source of a plurality of second claim data processing rules, wherein said rules processor applies said second claim data processing rules to said validation claim data group in deriving a plurality of second claim output data.

10. A system including at least one hardware processing device for simulating integrated system performance for changes to processing rules used for processing claim transaction message data related to reimbursement for provision of healthcare to a patient by specific payer organizations, comprising:

at least one repository of information including validation claim data, validation claim data processing rules and associated validation output data comprising a validation processing time duration corresponding to a processing time required to execute a plurality of iterations of applying said validation claim data processing rules to said validation claim data, wherein said validation claim data processing rules comprise payer organization rules and user organization specific rules;

a source of a plurality of modified claim data processing rules comprising;

a first set of modified claim data processing rules including at least one claim data processing rule that is different from at least one claim data processing rule of said validation claim data processing rules; and

a second set of modified claim data processing rules including at least one claim data processing rule that is different from at least one claim data processing rule of said first set of modified claim data processing rules and that is different from at least one claim data processing rule of said validation claim data processing rules;

a rules processor for executing a plurality of iterations of said first set of modified claim data processing rules and said second set of modified claim data processing rules and generating a first modified output data set and a second modified output data set by;

applying said first set of modified claim data processing rules and said second set of modified claim data processing rules to said validation claim data and executing said plurality of iterations;

automatically determining a first processing time duration for said first set of claim data processing rules corresponding to a processing time required to execute said plurality of iterations of said first set of claim data processing rules; and

automatically determining a second processing time duration for said second set of claim data processing rules corresponding to a processing time required to execute said plurality of iterations of said second set of claim data processing rules;

generating said first modified output data set comprising said first processing time duration and said second modified output data set comprising said second processing time duration;

a comparator for;

comparing said first modified output data set with said validation output data and with said second modified output data set;

comparing said second modified output data set with said validation output data and with said first modified output data set; and

identifying changed result data elements within one or more data fields between said validation output data, said first modified output data set and said second modified output data set;

a trace processor for producing a diagnostic trace log for tracing one or more execution errors of said first modified claim data processing rules and said modified claim data processing rules; and

an output processor for providing an indication of said first processing time duration and said second processing time duration, data representing said diagnostic trace log, and an electronic transaction message indicating said changed result data elements.

11. A system according to claim 10, wherein said validation claim data is in Extensible Markup Language (XML) compatible format and including a transformation processor for converting claim data to said validation claim data in XML format.

12. A system including at least one hardware processing device, for simulating integrated system performance for changes to processing rules used for processing a claim form and data related to reimbursement for provision of healthcare to a patient by specific payer organizations, comprising:

at least one repository including;

a model payer organization rules unit for isolating model payer organization rules, such that said model payer organization rules are protected from alteration,

a user organization rules unit, a plurality of sets of production claim data,

a plurality of sets of production claim data processing rules, wherein each set of said plurality of sets of production claim data processing rules corresponds to a set of said plurality of sets of production claim data,

associated output data comprising a plurality of sets of production claim result information representing a plurality of production processing time durations, wherein each set of said plurality of sets of production claim result information corresponds to output data obtained by processing said each set of said plurality of sets of production claim data processing rules and said corresponding set of said plurality of sets of production claim data;

a source of a set of modified claim data processing rules, said set of modified claim data processing rules being compatible with said model payer organization rules;

a rules processor for applying said set of modified claim data processing rules to a selected set of said production claim data in deriving a set of modified claim result information representing modified processing time duration;

a comparator for comparing said set of modified claim result information with at least one set of production claim result information to identify a changed processing time duration;

a trace processor for producing a diagnostic trace log for tracing an execution of said at least one set of production claim data processing rules and said modified claim data processing rules, said trace log including an indication of a failure of the execution of one or more rules; and

an output processor for providing an indication of said changed processing time duration, data representing said diagnostic trace log, and an electronic transaction message indicating said changed result data elements.

13. One or more hardware processors storing non-transitory machine-readable instructions that, when used by one or more computing devices, cause the one or more computing devices to perform a method for simulating integrated system performance for changes to processing rules used for processing claim data related to reimbursement for provision of healthcare to a patient by specific payer organizations, comprising the activities of:

storing in at least one repository, information including first claim data, a set of first claim data processing rules and associated output data comprising first claim result information representing a first processing time duration, wherein a performance throughput of said set of first claim data processing rule has been validated, and a first claim form comprising a plurality of data fields individually including claim data elements derived by applying said first claim data processing rules to said first claim data;

storing a set of second claim data processing rules;

applying, by a rules processor, said set of second claim data processing rules to said first claim data in deriving second claim result information representing a second processing time duration, and a second claim form comprising a plurality of data fields individually including claim data elements and corresponding to said first claim result information;

comparing said second claim result information with said first claim result information to identify a changed processing time duration, and changed result data elements including change in both format of said plurality of data fields and values of said claim data elements within said data fields between said first claim form and said second claim form;

producing, by a trace processor, for a diagnostic trace log for tracing an execution of said set of first claim data processing rules and said second claim data processing rules, the trace log including an indication of a failure of the execution of one or more rules;

providing, via an output processor, data representing a visual display of said changed processing time duration, said second claim form highlighting data fields associated with said changed result data elements in said second claim form, and said diagnostic trace log; and

upon validating said second set of claim data processing rules, providing said second set of claim data processing rules to a production claim processing system for processing a plurality of non-test claims.