Practice management and billing automation system

• US 7,617,116 B2
• Filed: 08/03/2001
• Issued: 11/10/2009
• Est. Priority Date: 08/04/2000
• Status: Expired due to Fees

• Current Assignee: Athenahealth Incorporated
• Original Assignee: Athenahealth Incorporated
• Inventors: Stone, Steve, Park, Ed, Amar, Anshul, Park, Todd
• Primary Examiner(s): PASS, NATALIE
• Application Number:
  US09/921,654
• Publication Number:
  US 20020133503A1
• Time in Patent Office: 3,021 Days
• Field of Search: 705/34, 705 2- 4, 705/8, 705/51, 705/40, 705/7, 709/203, 709/223, 707/104.1, 707/102
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems

Abstract

A medical practice management system can be used to manage a medical practice. A medical practice management server communicates with a medical practice client user interface over a first network and communicates with a payor server over a second network. The medical practice management server receives information associated with a visit by a patient to the medical practice. Prior to using the information to create a claim, the medical practice management server automatically and repeatedly interacts with the information to ensure correct information by either applying one or more rules to the information or by performing one or more transactions with the payor server. The medical practice management server performs a correcting action in response to finding an error in the information and subsequently uses the information to create an insurance claim.

Claims

1. A computerized method for managing a medical practice comprising:

storing by a medical practice management server in a rules database a plurality of insurance rules comprising one or more classes of rules, each class of rules being associated with one of a plurality of payor servers;

receiving by the medical practice management server data indicative of a completed claim submission for a claim from a medical practice client, the claim being associated with a payor server; and

automatically interacting with the completed claim submission by the medical practice management server to correct an error in the completed claim submission, wherein the error is resolved by the medical practice client before processing the completed claim submission, by applying one or more rules from a class of rules associated with the payor server, wherein the one or more rules comprises a new rule, an updated rule, or both received from the payor server, the interacting step comprising;

the medical practice management server automatically associating a first claim status with the completed claim submission indicative of the claim not satisfying one of the one or more rules;

the medical practice management server transmitting data indicative of a claim edit screen to the medical practice client, the claim edit screen comprising a claim edit section for editing the completed claim submission and a claim error explanation portion to explain one or more errors in the completed claim submission to a medical care provider;

the medical practice management server receiving data indicative of an updated completed claim submission from the medical practice client;

the medical practice management server correcting the completed claim submission based on the updated completed claim submission; and

the medical practice management server automatically associating a second claim status with the completed claim submission indicative of the completed claim submission satisfying all of the one or more rules.

2. The method of claim 1, wherein the error comprises a formatting error of the completed claim submission based on a format defined by the payor server.

3. The method of claim 1, wherein the error comprises a typographical error or incomplete information of the completed claim submission.

4. The method of claim 1, wherein each class of rules of the plurality of insurance rules comprises a rule that has universal applicability to all claims for a payor server associated with the class of rules;

a rule that applies to one or more specific insurance packages from a plurality of insurance packages offered to medical care providers by the payor server associated with the class of rules; and

a rule that applies to specific medical care providers who provide care under one or more specific insurance packages.

5. The method of claim 1, wherein the interacting step farther comprises determining the completed claim submission is associated with the payor server based on information in the completed claim submission.

6. The method of claim 1, further comprising:

generating remittance advice for the updated completed claim submission;

parsing an electronic payment; and

allocating the electronic payment among charge line items for the completed claim submission.

7. The method of claim 6, further comprising:

receiving approval from a medical care provider using the medical practice client for the allocated payments among the charge line items; and

posting the allocated payments to an account of the medical care provider.

8. The method of claim 1, wherein the interacting step further comprises associating a third claim status with the completed claim submission indicative of the completed claim submission comprising a detailed claim error.

9. The method of claim 1, further comprising:

submitting the completed claim submission to the payor server for payment;

associating an alarm with the completed claim submission, the alarm including data indicative of a submission time of the completed claim submission to the payor server; and

if a response from the payor server is not received within a predetermined amount of time from the submission time, triggering the alarm.

10. The method of claim 9, further comprising associating the completed claim submission with a claim inquiry grouping of claims, wherein the claim inquiry grouping of claims comprises claims that need to be followed up on.

11. The method of claim 1, wherein the claim edit screen comprises an explanation portion that denotes an error in the completed claim submission identified by applying the one or more rules from the class of rules associated with the payor server.

12. The method of claim 1, further comprising:

applying the one or more rules from the class of rules associated with the payor server to the completed claim submission; and

associating the second claim status with the completed claim submission if no errors are found by the one or more rules.

13. The method of claim 1, further comprising:

submitting the completed claim submission to the payor server for payment;

receiving a payment from the payor server for the completed claim submission;

applying the payment to the completed claim submission; and

associating a third claim status with the completed claim submission indicative of the payment being applied to the completed claim submission.

14. The method of claim 1, further comprising transmitting data indicative of a claim entry screen to the medical practice client, the claim edit screen comprising (a) a patient claim information section, (b) a procedure section, and (c) a hint section.

15. The method of claim 1, further comprising:

determining if the completed claim submission is billable based on the one or more rules from the class of rules associated with the payor server; and

automatically editing the completed claim submission based on information received from a rules engine, the information comprising edits to be performed to make the completed claim submission billable.

16. The method of claim 1, wherein the interacting step further comprises:

checking a claim rule category and a service date of the completed claim submission; and

defining claim information requirements and claim formatting rules based on the claim rule category and service date, wherein the claim information requirements are used to verify the completed claim submission and the formatting rules are used to format the completed claim submission.

17. The method of claim 1, further comprising transmitting data indicative of a claim review screen to the medical practice client to illustrate one or more errors in the claim, the claim review screen comprising a claim warnings section for denoting one or more warnings associated with the claim, wherein receiving data indicative of the completed claim submission comprises receiving data indicative of changes made by the medical practice client based on the errors denoted in the claim review screen and the claim error explanation portion of the claim edit screen.

18. A computerized method for managing a medical practice comprising:

storing by a medical practice management server in a rules database a plurality of insurance rules comprising one or more classes of rules, each class of rules being associated with one of a plurality of payor servers;

receiving by the medical practice management server data indicative of a completed claim submission for a claim from a medical practice client, the claim being associated with a payor server;

automatically interacting with the completed claim submission by the medical practice management server to correct an error in the completed claim submission, wherein the error is resolved by the medical practice client before processing the completed claim submission, by applying one or more rules from a class of rules associated with the payor server, wherein the one or more rules comprises a new rule, an updated rule, or both received from the payor server, the interacting step comprising;

the medical practice management server automatically associating a first claim status with the completed claim submission indicative of the claim not satisfying one of the one or more rules;

the medical practice management server transmitting data indicative of a claim edit screen to the medical practice client, the claim edit screen comprising a claim edit section for editing the completed claim submission and a claim error explanation portion to explain one or more errors in the completed claim submission to a medical care provider;

the medical practice management server receiving data indicative of an updated completed claim submission from the medical practice client;

the medical practice management server correcting the completed claim submission based on the updated completed claim submission; and

the medical practice management server automatically associating a second claim status with the completed claim submission indicative of the completed claim submission satisfying all of the one or more rules;

the medical practice management server formatting the completed claim submission into information having a form acceptable to the payor server using claim formatting rules;

the medical practice management server transmitting the information to the payor server; and

the medical practice management server automatically associating a third claim status with the completed claim submission indicative of the information being transmitted to the payor server.

19. The method of claim 18, wherein the claim formatting rules are based on a claim rule category and a service date of the completed claim submission.

20. A computerized method for managing a medical practice comprising:

storing by a medical practice management server in a rules database a plurality of insurance rules comprising one or more classes of rules, each class of rules being associated with one of a plurality of payor servers;

receiving data by the medical practice management server indicative of a completed claim submission for a claim from a medical practice client, the claim being associated with a payor server;

automatically interacting with the completed claim submission by the medical practice management server to correct an error in the completed claim submission, wherein the error is resolved by the medical practice client before processing the completed claim submission, by applying one or more rules from a class of rules associated with the payor server, wherein the one or more rules comprises a new rule, an updated rule, or both received from the payor server, the interacting step comprising;

the medical practice management server automatically associating a first claim status with the completed claim submission indicative of the claim not satisfying one of the one or more rules;

the medical practice management server transmitting data indicative of a claim edit screen to the medical practice client, the claim edit screen comprising a claim edit section for editing the completed claim submission and a claim error explanation portion to explain one or more errors in the completed claim submission to a medical care provider;

the medical practice management server receiving data indicative of an updated completed claim submission from the medical practice client;

the medical practice management server correcting the completed claim submission based on the updated completed claim submission; and

the medical practice management server automatically associating a second claim status with the completed claim submission indicative of the completed claim submission satisfying all of the one or more rules;

the medical practice management server receiving data indicative of a new rule, an updated rule, or both from the payor server; and

the medical practice management server automatically updating the class of rules associated with the payor server to reflect the received data.