Health care payment adjudication and review system

• US 5,359,509 A
• Filed: 10/31/1991
• Issued: 10/25/1994
• Est. Priority Date: 10/31/1991
• Status: Expired due to Term

• Current Assignee: United Healthcare Incorporated
• Original Assignee: United Healthcare Incorporated
• Inventors: Little, John P., McMahon, R. Scott, Gingrich, Mark, Martin, Roleigh H.
• Primary Examiner(s): Envall, Jr., Roy N.
• Assistant Examiner(s): Hazard, Jennifer L.
• Application Number:
  US07/786,123
• Time in Patent Office: 1,090 Days
• Field of Search: 364/401, 364/413.01, 364/406, 364/408, 395/924, 395/925
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 70/20 relating to practices or guidelines
• CPC Class Codes: Y10S 706/924 Medical

Abstract

A computerized expert system reviews and adjudicates medical health care payment requests made by physicians to payers, such as insurers, for procedures performed and services and materials rendered to patients in the course of treatment. The system adjudicates a payment request to minimize fraud and mistakes and to determine whether to honor the request and if the request is honored, the dollar amount of the payment. The expert system reviews the payment request based on user-specified review criteria. Such criteria reflects contractual arrangements between payers, providers and patients, current, locally acceptable medical practices and patient and provider payment request patterns.

To perform the review, the expert system obtains relevant prior payment requests as necessary according to the user'"'"'s pre-determined review criteria; defines a master list of payable payment requests given current medical procedures, the predetermined parameters of the review and specific contractual arrangements between the payer, patient and health care provider; analyses the current payment request according to the relevant historical payment requests and the master payable list by applying user-defined interpretive rules to this information; and develops and reports payment decisions based on that analysis.

Claims

1. In a networked computer processing system including first processor means for executing computer programs and having an associated storage means for storing data and one or more second processor means for executing computer programs, each second processor having an associated storage means for storing data, each of the second processor means being operably connected to the first processor means, a method for processing and adjudicating health care payment requests comprising the steps of:

(a) providing the first processor means with database information stored in the storage means, including;

(a1) a current payment request database having information relating to a plurality of outstanding health care payment requests, each health care payment request having one or more payment request line items corresponding to a specific medical procedure or supply for which payment is being requested;

(a2) a historical payment request database having information relating to a plurality of previously stored health care payment requests;

(a3) a plurality of procedure code list files, each of the procedure code list files having information relating to a certain medical procedure or supply and created according to one or more user-defined characteristics from a predefined complete set of medical procedures and supplies; and

(a4) a class file having information relating to classification of the predefined complete set of medical procedures and supplies and created according to a predefined set of body systems;

(b) providing each of the second processor means with an expert-based computer program including a set of user-defined rules and knowledge database information for the expert-based computer program stored in the storage means of the second processor means;

(c) using the first processor means to perform the steps of;

(c1) creating a payment request list from the current request database by selecting one or more payment request line items in response to a user-specified review code;

(c2) creating a master list file by logically combining the plurality of procedure code list files with each other in response to the user-specified review code;

(c3) for each payment request line item in the payment request list, creating a record in a communication file containing;

(c31) information from the current payment request database relating to the payment request line item;

(c32) information from the historical payment request database relating to a subset of relevant payment request line items selected from the historical payment request database;

(c33) information from the master list file relating to the procedure or supply for which payment is being requested by the payment request line item; and

(c34) information from the class file relating to the procedure or supply for which payment is being requested by the payment request line item; and

(c4) communicating the communication file to one or more of the second processor means;

(d) receiving the communication file and storing the communication file in the storage means of at least one of the second processor means and executing the expert-based computer program on the second processor means to perform the following steps for each payment request line item in the communication file;

(d2) using the set of user-defined rules and knowledge database information to determine the consistency of '"'"'the payment request line item as compared to the information from the subset of relevant payment request line items selected from the historical payment database;

(d2) using the set of user-defined rules and knowledge database information and the information from the master list file and the class file to determine the validity of the payment request line item;

(d3) making a decision on whether to pay the payment request line item based upon the consistency and validity of the payment request line item and the set of user-defined rules and knowledge database information;

(d4) if the payment request line item is to be paid, determining an amount of a payment for the payment request line item based upon the consistency and validity of the payment request line item and the set of user-defined rules and knowledge database information; and

(d5) generating an updated communication file to be communicated to the first processor means, the updated communication file including;

(d51) the decision on whether to pay each payment request line item in the communication file;

(d52) the amount of the payment for each payment request line item in the communication file that is to be paid; and

(d53) one or more items of coded information representing why the payment request line item is not to be paid for each payment request line item that is not to be paid; and

(e) receiving the updated communication file from each of the one or more second processor means and using the first processor means to update the current request database to generate the historical request database.

2. The method of claim 1 wherein the current request database and the historical request database are stored as part of a single payment request database.

3. The method of claim 1, further comprising the steps of:

(f) using the first processor means to analyze the updated communication file in response to a user request and generate one or more pre-defined reports summarizing the payment request line items.

5. The method of claim 3, wherein the updated communication file further includes

(d54) workload information representing the assignment of a payment request to a medical analyst for further review.

6. The method of claim 3, wherein the first processor means further includes

(c5) means for receiving the updated communication file from the one or more second processor means and updating the current request database to generate the historical request database.

4. An apparatus for processing and adjudicating health care payment requests on a networked computer processing system, the apparatus comprising:

first processor means for executing computer programs and having an associated storage means for storing data, the data including;

a current payment request database having information relating to a plurality of outstanding health care payment requests, each health care payment request having one or more payment request line items corresponding to a specific medical procedure or supply for which payment is being requested;

a historical payment request database having information relating to a plurality of previously stored health care payment requests;

a plurality of procedure code list files, each of the procedure code list files having information relating to a certain medical procedures or supplies and created according to one or more used-defined characteristics from a predefined complete set of medical procedures and supplies; and

a class file having information relating to classification of the predefined complete set of medical procedures and supplies and created according to a predefined set of body systems; and

one or more second processor means for executing computer programs, each second processor having an associated storage means for storing data, each of the second processor means being operably connected to the first processor means and being provided with an expert-based computer program including a set of user-defined rules and knowledge database information for the expert-based computer program stored in the storage means;

the first processor means including;

means for creating a payment request list from the current request database by selecting payment request line items in response to a user-specified review code;

means for creating a master list file by logically combining the plurality of procedure code list files with each other in response to the user-specified review code;

means for creating a record in a communication file for each payment request line item in the payment request list, said record containing;

information from the current payment request database relating to the payment request line item;

information from the historical payment request database relating to a subset of relevant payment request line items selected from the historical payment database;

information from the master list file relating to the procedure or supply for which payment is being requested by the payment request line item; and

information from the class file relating to the procedure or supply for which payment is being requested by the payment request line item; and

means for communicating the communication file to one or more of the second processor means;

the one or more second processor means, each including means for receiving the communication file and storing the communication file in the storage means of the second processor means and means for executing the expert-based computer program on the second processor means for each payment request line item in the communication file, including;

means for using the set of user-defined rules and knowledge database information to determine the consistency of the payment request line item as compared to the information from the subset of relevant payment request line items selected from the historical payment database;

means for using the set of user-defined rules and knowledge database information and the information from the master list file and the class file to determine the validity of the payment request line item;

means for making a decision on whether to pay the payment request line item based upon the consistency and validity of the payment request line item and the set of user-defined rules and knowledge database information;

if the payment request line item is to be paid, means for determining an amount of a payment for the payment request line item based upon the consistency and validity of the payment request line item and the set of user-defined rules and knowledge database information; and

means for generating the updated communication file to be communicated to the first processor means, the updated communication file including;

coded information representing the decision on whether to pay each payment request line item in the communication file;

coded information representing the amount of the payment for each payment request line item in the communication file that is to be paid; and

coded information representing why the payment request line item is not to be paid for each payment request line item that is not to be paid.

7. In a networked computer processing system, a method for using a plurality of historical payment requests stored in a database in the networked computer processing system in the adjudication of one or more current payment requests, the method comprising the computer-implemented steps of:

(a) identifying one or more initial selection criteria to be used for selecting a set of the relevant historical payment requests;

(b) creating the set of one or more relevant historical payment requests in response to one or more of the initial selection criteria by selecting the historical payment requests that match the initial selection criteria;

(c) identifying one or more screening criteria to screen the set of relevant historical payment requests selected in (b) for pertinent information;

(d) collecting information from the set of relevant historical payment requests selected in step (b) using the screening criteria to sort the historical payment requests containing information that matches the screening criteria and storing said information in a communications file;

(e) sorting information stored in the communications file according to predetermined presentation order.

8. The method of claim 7 wherein the initial selection criteria is identified according to a user-defined review code criteria.

9. The method of claim 7 wherein the predetermined presentation order is based on a user-defined review code criteria.

10. The method of claim 7 further comprising the computer-implemented steps of:

(f) storing the sorted communications file; and

(g) outputting the stored communication file for analysis.