Automated claim repricing system

• US 6,792,410 B1
• Filed: 05/07/1999
• Issued: 09/14/2004
• Est. Priority Date: 05/07/1999
• Status: Expired due to Term

• Current Assignee: HFN, Inc. (Zelis Healthcare, Inc.)
• Original Assignee: HFN, Inc. (Zelis Healthcare, Inc.)
• Inventors: Donovan, Edward Joseph, Towner, Wendy Marie, Berthaud, Christian
• Primary Examiner(s): RIMELL, SAMUEL G
• Application Number:
  US09/307,136
• Time in Patent Office: 1,957 Days
• Field of Search: 705/1, 705/2, 705/3, 705/4, 705/30, 709/200, 709/201, 709/202
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

The present claim repricing system generally includes a processor and a program and data memory coupled to the processor. The memory stores the requisite database tables, as well as program instructions for repricing several different types of claims, including physician, inpatient, and outpatient claims. The claim repricing system includes instructions for determining availability of insurance plan coverage to the patient based on an effective date of the employer insurance plan, as well as determining the availability of the physician or provider based on an effective provider date. The claim repricing system further handles specialty codes and exceptions. For example, the claim repricing system includes instructions for determining the presence of anesthesia specialty codes, and for determining the correct number of anesthesia units and an anesthesia repricing indicator. The anesthesia repricing indicator may be a percentage discount, for example, or a rate. Furthermore, the claim repricing system may operate in a batch processing mode to quickly, accurately, and reliable reprice large amounts of claims.

Claims

1. A claim processing system for repricing insurance claims, the system comprising:

a processor; and

a memory coupled to the processor, the memory encoded with;

instructions for storing service charges identified by at least one uniform code;

instructions for identifying a physician from a database of physicians according to a physician ID;

instructions for identifying a patient from a database of patients;

instructions for determining an employer insurance plan providing coverage for the patient;

instructions for determining a repricing indicator based on an affiliation of the physician and the employer insurance plan;

instructions for performing a course validation to determine if at least one of information for identifying a physician, identifying a patient and identifying an employer insurance plan is present;

instructions for repricing the service charges according to the repricing indicator to generate repriced service charges; and

instructions for performing a detailed validation to determine if at least said repriced service charges are valid.

2. The claim processing system of claim 1, wherein the repricing indicator is a fee schedule comprising individual repricing amounts associated with CPT codes.

3. The claim processing system of claim 1, wherein the repricing indicator is a percentage discount.

4. The claim processing system of claim 1, wherein the computer readable memory further comprises instructions for generating a repricing report showing each of the repriced service charges.

5. The claim processing system of claim 1, wherein the computer readable memory further comprises instructions for determining availability of insurance plan coverage to the patient based on an effective date of the employer insurance plan.

6. The claim processing system of claim 1, wherein the computer readable memory further comprises instructions for determining the availability of the physician based on an effective provider date.

7. The claim processing system of claim 1, wherein the computer readable memory further comprises instructions for determining the presence of a specialty repricing code.

8. The claim processing system of claim 7, wherein the specialty repricing code is an anesthesia code.

9. The claim processing system of claim 8, wherein the computer readable memory further comprises instructions for determining a total number of anesthesia units and for determining an anesthesia repricing indicator.

10. The claim processing system of claim 9, wherein the instructions for determining a total number of anesthesia units includes instructions for determining a number of anesthesia modifier units.

11. The claim processing system of claim 9, wherein the anesthesia repricing indicator is a percentage discount.

12. The claim processing system of claim 9, wherein the anesthesia repricing indicator is a rate.

13. A claim processing system for repricing insurance claims, the claim processing system comprising:

a processor; and

a memory coupled to the processor, the memory encoded with;

instructions for identifying a provider from a database of providers according to a provider ID;

instructions for identifying a patient from a database of patients;

instructions for identifying an employer based on an insured-by ID associated with the patient;

instructions for identifying a weight and a rate based on the employer and the provider;

instructions for performing a course validation to determine if at least one of information for identifying a provider, identifying a patient and identifying an employer is present;

instructions for repricing a total service charge based on the weight and the rate to generate a repriced claim amount; and

instructions for performing a detailed validation to determine if at least said repriced claim amount is valid.

14. The claim processing system of claim 13, wherein the weight is a Diagnostic Related Group (DRG) weight and the rate is a DRG rate.

15. The claim processing system of claim 13, wherein the computer readable memory further comprises instructions for determining whether the provider was effective at a predetermined date.

16. The claim processing system of claim 15, wherein the computer readable memory further comprises instructions for determining whether the employer was effective at a predetermined date.

17. The claim processing system of claim 13, wherein the computer readable memory further comprises instructions for identifying a stop loss and a stop loss discount based on the provider, and instructions for applying the stop loss discount to the total service charge when the total service charge is greater than the stop loss.

18. The claim processing system of claim 13, wherein the computer readable memory further comprises instructions for applying a DRG discount to the total service charge when the repriced claim amount is greater than the total service charge.

19. The claim processing system of claim 13, wherein the computer readable memory further comprises instructions for identifying an insurance plan carried by the employer and for determining a differential and a union status according to the insurance plan.

20. The claim processing system of claim 19, wherein the computer readable memory further comprises instructions for terminating repricing when the differential and the union status do not qualify the patient for coverage at the provider.

21. The claim processing system of claim 13, wherein the computer readable memory further comprises instructions for determining a claim repricing exception associated with the provider.

22. The claim processing system of claim 21, further comprising instructions for applying a repricing rule determined by the claim repricing exception.

23. A claim processing system for repricing insurance claims, the claim processing system comprising:

a processor; and

a memory coupled to the processor, the memory encoded with;

instructions for determining what type of claim to reprice from a plurality of claims recognized by the claim processing system;

instructions for identifying a provider from a database of providers according to a provider ID;

instructions for identifying a patient from a database of patients;

instructions for identifying an employer and an employer insurance plan associated with the patient;

instructions for storing a claim comprising at least one line item service charge;

surgical repricing instructions for repricing the claim when a line item is a surgical line item;

instructions for performing a course validation to determine if at least one of information for identifying a provider, identifying a patient, identifying an employer and identifying an employer insurance plan is present;

non-surgical repricing instructions for repricing individual line items when no line item is a surgical line item; and

instructions for performing a detailed validation to determine if at least one of a repriced claim and a repriced individual line item is valid.

24. The claim processing system of claim 23, further comprising instructions for determining a stop loss and a stop loss discount and applying the stop loss discount to a total service charge when the total service charge exceeds the stop loss.

25. The claim processing system of claim 23, further comprising instructions for determining a discount associated with the employer insurance plan, and wherein the non-surgical repricing instructions comprise instructions for applying the discount to the line items to generate repriced line items.

26. The claim processing system of claim 23, further comprising instructions for determining whether the provider was effective at a predetermined date.

27. The claim processing system of claim 26, further comprising instructions for determining whether the employer was effective at a predetermined date.

28. The claim processing system of claim 23, further comprising instructions for determining a differential and a union status according to the insurance plan.

29. The claim processing system of claim 28, further comprising instructions for terminating repricing when the differential and the union status do not qualify the patient for coverage at the provider.

30. The claim repricing system of claim 23, wherein the surgical repricing instructions comprise instructions for determining a repricing indicator based on each line item and instructions for repricing each line item according to the repricing indicator.

31. The claim processing system of claim 30, wherein the repricing indicator is a dollar amount based on an Ambulatory Surgical Code table.

32. The claim processing system of claim 30, further comprising instructions for determining a repricing exception and for applying an exception repricing rule determined by the repricing exception to a line item.

33. The claim processing system of claim 32, wherein the exception repricing rule is applied after repricing each line item.