System and method for electronic remittance notice analysis
First Claim
1. An electronic remittance notice analysis system, comprising:
- a database component operable to maintain electronic remittance notice information for a plurality of healthcare providers, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of the plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes information for each of the plurality of claims that includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and financial information; and
a processor component operable to access the database component and determine, for a period of time and for a plurality of claims, an average denial rate for each of the plurality of procedures for one of the plurality of healthcare providers, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the financial information, the processor further operable to determine a weighted average denial rate for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and a weighted average aggregate denial rate for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, the processor component is further operable to compare the weighted average denial rate and the weighted average aggregate denial rate, and the processor component is further operable to determine a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer.
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Accused Products
Abstract
A system and method for analyzing electronic remittance notices (ERNs) is provided. The system includes a database component and a processor component for determining benchmark, for both denial rates and/or days sales outstanding, weighted average values for a particular provider and weighted average aggregate values based on a plurality of providers ERN claim adjudication information. The ERN information may originate from one or more third-party payers for claims for medical products or procedures. The weighting of these values may mimic or approximate a particular healthcare provider'"'"'s mix of medical products and/or services to provide much more meaningful information. This benchmark values may be compared to various other ERN metrics of ERN claim adjudication information to compare to aggregate healthcare provider information. Equalizer values may also be calculated, analyzed and compared.
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Citations
60 Claims
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1. An electronic remittance notice analysis system, comprising:
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a database component operable to maintain electronic remittance notice information for a plurality of healthcare providers, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of the plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes information for each of the plurality of claims that includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and financial information; and a processor component operable to access the database component and determine, for a period of time and for a plurality of claims, an average denial rate for each of the plurality of procedures for one of the plurality of healthcare providers, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the financial information, the processor further operable to determine a weighted average denial rate for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and a weighted average aggregate denial rate for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, the processor component is further operable to compare the weighted average denial rate and the weighted average aggregate denial rate, and the processor component is further operable to determine a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
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15. An electronic remittance notice analysis system, comprising:
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a database component operable to maintain electronic remittance notice information for a plurality of healthcare providers, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of the plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes information for each of the plurality of claims that includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and payment information; and a processor component operable to access the database component and determine, for a period of time and for a plurality of claims, an average days sales outstanding for each of the plurality of procedures for one of the plurality of healthcare providers, an average aggregate days sales outstanding for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the payment information, the processor is further operable to determine a weighted average days sales outstanding for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and a weighted average aggregate days sales outstanding for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers, and the processor component is further operable to determine a percentage difference between the weighted average days sales outstanding and the weighted average aggregate days sales outstanding to generate a days sales outstanding equalizer. - View Dependent Claims (16, 17, 18, 19)
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20. A computerized method for analyzing electronic remittance notice information, comprising:
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receiving electronic remittance notice information from a third party payer in a computer database, the electronic remittance notice information includes claim adjudication information for a plurality of claims for each of a plurality of healthcare providers and for a plurality of procedures, the claim adjudication information includes healthcare provider identifier information, date information, procedure information, denial/allowance information, and financial information; determining, for a period of time and for the plurality of claims for each of the plurality of procedures, an average denial rate for each of the plurality of procedures for one of the plurality of healthcare providers; determining, for the period of time and based upon at least part of the plurality of claims, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers; determining a weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers based on the financial information; determining a weighted average denial rate for the period of time for the one of the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers; and determining a weighted average aggregate denial rate for the period of time for the plurality of healthcare providers based on the weighting factor for each of the plurality of procedures for the one of the plurality of healthcare providers; comparing the weighted average denial rate and the weighted average aggregate denial rate; determining a percentage difference between the weighted average denial rate and the weighted average denial rate to generate a denial rate equalizer; and outputting reports of custom benchmark information generated by the method;
wherein one or more steps are performed by one or more computers. - View Dependent Claims (21, 22, 23, 24, 25, 26)
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27. An electronic remittance notice analysis system comprising:
one or more processor components operable to; receive electronic remittance notice information regarding a plurality of claims for each of a plurality of healthcare providers and for a plurality of procedures, determine, for a selection of the plurality of claims, an average denial rate for each of the plurality of procedures for a selected one of the plurality of healthcare providers, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the selected one of the plurality of healthcare providers, a weighted average denial rate for the selected one of the plurality of healthcare providers based on the weighting factor and the average denial rate, and a weighted average aggregate denial rate for the plurality of healthcare providers based on the weighting factor and the average aggregate denial rate, and determine a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer. - View Dependent Claims (28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47)
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48. An electronic remittance notice analysis system comprising:
one or more processor components operable to; receive electronic remittance notice information regarding a plurality of claims for each of a plurality of healthcare providers and for a plurality of procedures, determine, for a selection of the plurality of claims, an average days sales outstanding for each of the plurality of procedures for a selected one of the plurality of healthcare providers, an average aggregate days sales outstanding for each of the plurality of procedures for the plurality of healthcare providers, a weighting factor for each of the plurality of procedures for the selected one of the plurality of healthcare providers a weighted average days sales outstanding for the selected one of the plurality of healthcare providers based on the weighting factor and the average days sales outstanding, and a weighted average aggregate days sales outstanding for the plurality of healthcare providers based on the weighting factor, and determine a percentage difference between the weighted average days sales outstanding and the weighted average aggregate days sales outstanding to generate a days sales outstanding equalizer. - View Dependent Claims (49, 50, 51, 52, 53)
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54. A computerized method for analyzing electronic remittance notice information, the method comprising, in one or more processor components:
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receiving electronic remittance notice information regarding a plurality of claims for each of a plurality of healthcare providers and for a plurality of procedures; determining, for the plurality of claims for each of the plurality of procedures, an average denial rate for each of the plurality of procedures for a selected one of the plurality of healthcare providers; determining, for at least part of the plurality of claims, an average aggregate denial rate for each of the plurality of procedures for the plurality of healthcare providers; determining a weighting factor for each of the plurality of procedures for the selected one of the plurality of healthcare providers; determining a weighted average denial rate for the selected one of the plurality of healthcare providers based on the weighting factor and the average denial rate; determining a weighted average aggregate denial rate for the plurality of healthcare providers based on the weighting factor and the average aggregate denial rate; and determining a percentage difference between the weighted average denial rate and the weighted average aggregate denial rate to generate a denial rate equalizer. - View Dependent Claims (55, 56, 57, 58, 59, 60)
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Specification