|
Insurance Abstract
In a system and method for verifying the accurate processing of
medical insurance claim data generated by a health care provider,
a health care provider enters medical insurance claim information
(data) into a health care provider terminal. The medical insurance
claim data may include patient identification data and treatment
data. The health care provider terminal stores and transmits the
medical insurance claim data to a medical insurance claim processor
operated by a medical insurance company. The medical insurance claim
processor processes the claim data received from the health care
provider terminal and generates processed claim data. Processed
claim data may include patient identification data, treatment data,
and payment data. Upon receipt of the processed claim data, the
health care provider terminal compares the processed claim data
with the stored medical insurance claim data originally submitted
to the medical insurance claim processor. The health care provider
terminal then generates comparison data indicating whether the stored
medical insurance claim data has been processed in accordance with
predetermined claim processing rules, which may be negotiated and
agreed to by the health care provider and the medical insurance
company. The comparison data also identifies processing errors,
if any, in the processed claim data received from the medical insurance
claim processor. The health care provider terminal may also generate
and retransmit revised medical insurance claim data when the processed
claim data has not been processed in accordance with the predetermined
processing rules. Also, the health care provider terminal may automatically
retransmit the medical insurance claim data to the medical insurance
claim processor when the medical insurance claim data have not been
processed within a defined period of time. Additionally, the health
care provider terminal may verify the accuracy of treatment data
prior to transmitting the medical insurance claim data to the medical
insurance claim processor.
Insurance Claims
1. A health care provider terminal for verifying the accurate processing
of medical insurance claims generated by a health care provider,
comprising: means for inputting medical insurance claim data; means
for transmitting said medical insurance claim data to a medical
insurance claim processor; means for storing said medical insurance
claim data and processed claim data generated by said medical insurance
claim processor in response to said medical insurance claim data;
means for comparing said medical insurance claim data and said processed
claim data to determine whether said medical insurance claim data
has been processed in accordance with predetermined processing rules,
wherein said comparing means generates comparison data that indicates
whether said processed claim data has been processed in accordance
with said predetermined processing rules and identifies any processing
errors in said processed claim data.
2. A health care provider terminal according to claim 1, wherein
said predetermined processing rules are negotiated and agreed to
by said health care provider and an insurance company that operates
said medical insurance claim processor.
3. A health care provider terminal according to claim 1, wherein
said processed claim data is received by said health care provider
terminal electronically from said medical insurance claim processor.
4. A health care provider terminal according to claim 1, wherein
said processed claim data is entered into said health care provider
terminal via said inputting means.
5. A health care provider terminal according to claim 1, wherein
said medical insurance claim data and said processed claim data
include patient identification data and treatment data.
6. A health care provider terminal according to claim 1, wherein
said processed claim data include payment data indicating an amount
to be paid to said health care provider in response to said medical
insurance claim data.
7. A health care provider terminal according to claim 1, further
comprising: means for generating revised medical insurance claim
data when said processed claim data has not been processed in accordance
with said predetermined processing rules, wherein said transmitting
means transmits said revised medical insurance claim data to said
medical insurance claim processor.
8. A health care provider terminal according to claim 1, wherein
said transmitting means retransmits said medical insurance claim
data to said medical insurance claim processor when said medical
insurance claim data has not been processed by said medical insurance
claim processor within a defined period of time.
9. A health care provider terminal according to claim 5, further
comprising means for verifying the accuracy of said treatment data
using said predetermined processing rules prior to transmitting
said medical insurance claim data to said medical insurance claim
processor.
10. A method for verifying the accurate processing of medical insurance
claim data generated by a health care provider, comprising the steps
of: (a) inputting and storing medical insurance claim data; (b)
transmitting said medical insurance claim data to a medical insurance
claim processor; (c) receiving processed claim data generated by
said medical insurance claim processor in response to said medical
insurance claim data; (d) comparing said stored medical insurance
claim data and said processed claim data; and (e) generating comparison
data that indicates whether said medical insurance claim data has
been processed in accordance with predetermined processing rules.
11. A method according to claim 10, wherein said predetermined
processing rules are negotiated and agreed to by said health care
provider and an insurance company that operates said medical insurance
claim processor.
12. A method according to claim 10, wherein said processed claim
data is received electronically from said medical insurance claim
processor.
13. A method according to claim 10, wherein said processed claim
data is entered into a health care provider terminal by said health
care provider.
14. A method according to claim 10, wherein said medical insurance
claim data and said processed claim data include patient identification
data and treatment data.
15. A method according to claim 10, wherein said processed claim
data include payment data indicating an amount to be paid to said
health care provider in response to said medical insurance claim
data.
16. A method according to claim 10, further comprising the steps
of: (f) generating revised medical insurance claim data when said
processed claim data has not been processed in accordance with said
predetermined processing rules, and (g) storing said revised medical
insurance claim data, and (h) transmitting said revised medical
insurance claim data to said medical insurance claim processor.
17. A method according to claim 10, further comprising the step
of retransmitting said medical insurance claim data to said medical
insurance claim processor when said medical insurance claim data
has not been processed by said medical insurance claim processor
within a defined period of time.
18. A method according to claim 14, further comprising the step
of verifying the accuracy of said treatment data using said predetermined
processing rules prior to transmitting said medical insurance claim
data to said medical insurance claim processor.
19. A system for verifying the accurate processing of medical health
insurance claims submitted to a medical insurance company by a health
care provider, comprising: a device for inputting medical insurance
claim data, wherein said medical insurance claim data includes one
or more treatment codes; a transmitter for transmitting said medical
insurance claim data to a medical insurance claim processor; a storage
device for storing said medical insurance claim data and processed
claim data received in response to said medical insurance claim
data transmitted to said medical insurance claim processor; and
a processor for verifying the accuracy of said treatment codes in
said medical insurance claim data using predetermined processing
rules prior to transmitting said medical insurance claim data to
said medical insurance claim processor.
20. A system according to claim 19, wherein said processor generates
notification data when said medical insurance claim data has not
been processed in accordance with said predetermined processing
rules.
Insurance Description
FIELD OF THE INVENTION
[0001] The present invention relates to a system and method for
verifying the accurate processing of medical insurance claims prepared
and filed by health care providers for payment by medical insurance
companies. The present invention further relates to a system and
method for verifying the accuracy of medical insurance claims prior
to submission by health care providers to medical insurance companies.
BACKGROUND OF THE INVENTION
[0002] The processing of medical insurance claims generated when
health care providers ("providers") perform services for
patients is facilitated by computerized networks. In general, when
a provider treats a patient, the provider enters certain medical
insurance claim data into a computer using software programs designed
for this specific use. The claim data entered into the computer
is transmitted to one or more medical insurance companies. The medical
insurance companies process the claims, send processed claim information
back to the provider, and send financial compensation for the services
rendered by the provider.
[0003] Medical insurance claim data entered into a computer by
a provider generally include several types of codes, which may be,
for example, numeric or alphanumeric in format. Each code represents
an aspect of a provider's treatment of a patient. Types of codes
include examination codes, diagnostic codes, procedure codes and
supply codes. Examination codes represent the type of examination
performed by a provider on a patient. Diagnostic codes represent
the diagnosis(es) made by the provider concerning the patient's
condition, and the procedure codes indicate what services were performed
by the provider in order to treat the patient. Supply codes represent
supplies used to treat the patient, such as surgical trays, medications,
IV supplies, etc. A single visit by a patient to a provider may
result in one or more examinations of body systems and/or body parts,
one or more diagnoses, one or more procedures, and/or use of one
or more supplies, each of which is represented by a code when a
medical insurance claim is created and submitted to an insurance
company. Moreover, for each diagnostic code, there are defined allowable
procedure codes, and for each procedure code, there are defined
allowable supply codes. Thus, the codes reflect that only certain
procedures are appropriate in treating a given diagnosis, and that
only certain supplies are appropriate for performing certain procedures.
[0004] One commonly used collection of examination, diagnostic,
procedural and supply codes is published by the American Medical
Association (AMA), which regularly updates and publishes its codes.
The AMA also assigns point values to each examination, procedure,
and supply code. These point values are used in processing medical
insurance claims as described in detail below.
[0005] Before submitting claims to a medical insurance company,
a provider negotiates a contract with the insurance company that
dictates the terms by which the insurance company will reimburse
the provider for services performed on patients insured by the insurance
company. In the contract, the insurance company defines the reimbursement
terms using the point values assigned to each of the AMA procedure
and supply codes by assigning a conversion factor that translates
the points for each procedure and supply code into a dollar value.
Providers may negotiate different conversion factors with different
insurance companies. The conversion factor may also vary with geographic
location of the provider. In some cases, such as Medicare, the provider
does not have any opportunity to negotiate the terms of reimbursement:
Medicare's reimbursement terms and conversion factors are fixed.
[0006] For purposes of illustrating the existing system for processing
and reimbursement of medical insurance claims, an exemplary medical
insurance claim may be submitted to an insurance company as follows:
Date of Service
Patient Identification Number
Examination Code 1
Diagnostic Code 1
[0007] Procedure Code 1 [0008] Supply Code 1
[0009] Procedure Code 2
[0010] Procedure Code 3
Diagnostic Code 2
[0011] Procedure Code 1
[0012] Procedure Code 2 [0013] Supply Code 1 The date of service
represents the date on which the patient was seen and treated. The
patient's identification number may be the patient's Social Security
Number or any other identification number, often assigned by the
patient's medical insurance company. The Examination Code indicates
that the provider performed a certain type of examination on the
patient. The Diagnosis Codes represent the diagnoses made by the
provider concerning the patient's condition, the Procedure Codes
represent the procedures performed by the provider to treat the
patient, and the Supply Codes indicate what supplies were used in
performing the corresponding procedures.
[0014] When a medical insurance claim is received by a medical
insurance company or other medical insurance provider ("the
company"), the company processes the claim either automatically
or manually. Processed claim data and monetary payment are then
sent to the provider, via electronic or paper means.
[0015] Processed claim data generated in response to the example
claim above should be as follows:
Date of Service
Patient Identification Number
Examination 1--Amount reimbursed ($)
Diagnostic Code 1
[0016] Procedure Code 1--Amount reimbursed ($) [0017] Supply Code
1--Amount reimbursed ($)
[0018] Procedure Code 2--Amount reimbursed ($)
[0019] Procedure Code 3--Amount reimbursed ($)
Diagnostic Code 2
[0020] Procedure Code 1--Amount reimbursed ($)
[0021] Procedure Code 2--Amount reimbursed ($) [0022] Supply Code
1--Amount reimbursed ($)
[0023] In the existing system of medical insurance claim processing
and reimbursement, however, mistakes are very common. It is not
unusual for claims to be processed incorrectly or incompletely.
For example, the conversion factor used to calculate the amount
of money to be reimbursed to the provider may be incorrect, leading
to incorrect payments. Also, examination and/or procedural codes
may be omitted all together, such that the provider is not paid
for examinations and/or procedures performed or supplies used.
[0024] These types of mistakes and omissions are difficult to track
due to the shear volume of claims involved. A provider may send
hundreds of claims on a weekly basis, and manually checking each
one to insure proper processing and reimbursement is very burdensome.
In addition, the claims must be resubmitted to the insurance company
for correct processing, which adds to the burden placed on providers
and insurance companies.
[0025] Consequently, there is a need for a system for health care
providers to use to verify that their insurance claims are being
correctly processed and paid, to assist in resubmission of incorrectly
processed claims, and to assist in verifying the accuracy of claims
prior to submission to the insurance company.
SUMMARY OF THE INVENTION
[0026] In view of the drawbacks of the existing system for processing
and reimbursing medical insurance claims as described above, the
present invention provides a system and method that automatically
identify medical health insurance claim processing errors. In particular,
in the system and method according to the present invention, processed
claim data received from an insurance company is compared with the
original medical insurance claim data submitted to the insurance
company to verify that each examination, procedural, and/or supply
code has been processed and that the monetary amount reimbursed
for each supply, procedure and examination matches that amount due
under the contract between the provider and the insurance company.
The system and method according to the present invention may also
automatically resubmit erroneously processed claim data to the medical
insurance company until each claim is correctly and completely processed.
[0027] The system and method according to the present invention
may also check medical insurance claims prior to submission to the
insurance company to verify that the diagnostic codes, procedural
codes, and supply codes are correctly associated as defined by the
AMA or other coding system, thus avoiding the delay and burden imposed
on the provider when the claim is returned to the provider for correction
before any processing is performed.
[0028] Also, the system and method according to the present invention
may notify the provider of claims not processed within a given amount
of time, for example, 60 or 90 days after submission of the claim.
The system and method according to the present invention may further
automatically resubmit these unprocessed claims to the insurance
company to facilitate processing of the claims.
[0029] A system for verifying the accurate processing of medical
insurance claims generated by a health care provider in accordance
with the present invention includes health care provider terminal
with components for inputting medical insurance claim data, a transmitter
for transmitting the medical insurance claim data to a medical insurance
claim processor, a storage unit for storing the medical insurance
claim data and processed claim data received in response to the
medical insurance claim data transmitted to the medical insurance
claim processor, and a processor for comparing stored medical insurance
claim data and the processed claim data to determine whether the
medical insurance claim data has been processed in accordance with
predetermined processing rules. The processor generates comparison
data that indicates whether the processed claim data has been processed
in accordance with the predetermined processing rules. If there
are errors in the processed claim data, the comparison data also
identifies the specific errors in the processed claim data.
[0030] The health care provider terminal in accordance with the
present invention may also generate revised medical insurance claim
data when the processed claim data has not been processed in accordance
with the predetermined processing rules and transmit the revised
medical insurance claim data to the medical insurance claim processor.
Additionally, the health care provider terminal may retransmit the
medical insurance claim data to the medical insurance claim processor
when the medical insurance claim data has not been processed by
the medical insurance claim processor within a defined period of
time. The health care provider terminal may also verify the accuracy
of treatment data prior to transmitting the medical insurance claim
data to the medical insurance claim processor.
[0031] A method for verifying the accurate processing of medical
insurance claim data generated by a health care provider in accordance
with the present invention comprises the steps of inputting and
storing medical insurance claim data, transmitting the medical insurance
claim data to a medical insurance claim processor, receiving processed
claim data generated by the medical insurance claim processor in
response to the medical insurance claim data, comparing the stored
medical insurance claim data and the processed claim data, and generating
comparison data that indicates whether the medical insurance claim
data has been processed in accordance with predetermined processing
rules. If there are errors in the processed claim data, the comparison
data also identifies the specific errors in the processed claim
data.
[0032] The method according to the present invention may further
include the steps of generating revised medical insurance claim
data when the processed claim data has not been processed in accordance
with the predetermined processing rules and transmitting the revised
medical insurance claim data to the medical insurance claim processor.
[0033] The method according to the present invention may also include
the step of retransmitting the medical insurance claim data to the
medical insurance claim processor when the medical insurance claim
data has not been processed by the medical insurance claim processor
within a defined period of time.
[0034] In accordance with the present invention, the predetermined
processing rules may be negotiated and agreed to in a contract between
the health care provider and the insurance company that operates
the medical insurance claim processor. Also, the processed claim
data may be received electronically from the medical insurance claim
processor or entered into the health care provider terminal by the
health care provider. The medical insurance claim data and processed
claim data may include patient identification data and treatment
data. The processed claim data may include payment data indicating
the amount to be paid to the health care provider in response to
the medical insurance claim data.
[0035] An alternative system for verifying the accurate processing
of medical health insurance claims submitted to a medical insurance
company by a health care provider in accordance with the present
invention includes a device for inputting medical insurance claim
data having one or more treatment codes; a transmitter for transmitting
the medical insurance claim data to a medical insurance claim processor;
a storage device for storing the medical insurance claim data and
processed claim data received in response to the medical insurance
claim data transmitted to the medical insurance claim processor;
and a processor for verifying the accuracy of the treatment codes
in the medical insurance claim data using predetermined processing
rules prior to transmitting the medical insurance claim data to
the medical insurance claim processor. The processor may generate
notification data when the medical insurance claim data has not
been processed in accordance with the predetermined processing rules.
[0036] The foregoing and other features, aspects, and advantages
of the present invention will become more apparent from the following
detailed description when read in conjunction with the accompanying
drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
[0037] FIG. 1 provides a block diagram of the components of a preferred
embodiment of a system for verifying the accurate processing of
medical insurance claims in accordance with the present invention.
[0038] FIG. 2 provides a block diagram of the functionality of
a processor that may be used in the health care provider terminal
shown in FIG. 1.
[0039] FIG. 3 provides a block diagram of additional functionality
of a processor that may be used in the health care provider terminal
shown in FIG. 1 in which the processor notifies the health care
provider of claims not processed within a defined period of time.
[0040] FIG. 4 provides a block diagram of additional functionality
of a processor that may be used in the health care provider terminal
shown in FIG. 1 in which the processor checks the accuracy of medical
insurance claim data prior to its transmission to a medical insurance
claim processor.
[0041] FIG. 5 provides a block diagram of a method for verifying
the accurate processing of medical insurance claim data in accordance
with the present invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0042] The present invention will now be described with reference
to the accompanying drawings, which are provided as illustrative
examples of preferred embodiments of the present invention. Notably,
the present invention may be implemented using software, hardware
or any combination thereof as would be apparent to one of skill
in the art.
[0043] FIG. 1 depicts a preferred embodiment of a health care provider
terminal 101 such as could be found in a doctor's office, health
clinic, hospital, dental office, or any other place in which health
care services are rendered to patients. With reference to FIG. 1,
terminal 101 according to the present invention includes a keyboard,
computerized dictation system, or other wired or wireless data input
device 110 used to input medical insurance claim data into terminal
101. Medical insurance claim data entered via the input device 110
is stored in a storage device 111, which may be any type of data
storage device, such as a hard drive, CD-ROM, DVD, floppy disk,
flash memory, or other data storage device as would be apparent
to one of skill in the art.
[0044] Terminal 101 also includes a processor 112 that receives
medical insurance claim data from input device 110 that facilitates
the storage of the data in storage device 111 and processes the
data and other data as described below with reference to FIGS. 2-4.
Processor 112 also provides the medical insurance claim data to
a transmitter/receiver 113 for transmitting and receiving data.
Transmitter/receiver 113 may be any type of transmitter/receiver
for sending and receiving data, such as a modem coupled to a telephone
line, broadband connection, satellite connection, Internet connection,
or cable connection, or any other wired or wireless data communication
network as would be apparent to one of skill in the art. Transmitter/receiver
113 receives medical insurance claim data from processor 112 and
transmits it to a medical insurance claim processor 102, which is
operated by a medical insurance company.
[0045] In accordance with one embodiment of the present invention,
medical insurance claim processor 102 transmits processed claim
data back to terminal 101 via transmitter/receiver 113, which provides
the processed claim data to processor 112.
[0046] In accordance with an alternative embodiment of the present
invention, processed claim data is received by the health care provider
in paper or other form and is entered into terminal 101 by the health
care provider using input device 110.
[0047] Once the processed claim data is received by terminal 101,
processor 112 retrieves from storage 111 the medical insurance claim
data corresponding to the processed claim data and compares the
medical insurance claim data to the processed claim data in order
to determine whether the medical insurance claim data was accurately
processed by medical insurance claim processor 102 in accordance
with predetermined processing rules. This comparison process performed
by processor 112 and the predetermined processing rules are described
in further detail below with reference to FIG. 2.
[0048] Based upon the comparison of the stored medical insurance
claim data stored in storage 111 to the processed claim data received
from the medical insurance claim processor 102, processor 112 generates
comparison data. If the medical insurance claim data submitted to
the medical insurance claim processor by terminal 101 has been correctly
processed by the medical insurance claim processor 102 in accordance
with the predetermined processing rules, processor 112 generates
comparison data to indicate that the claim data has been processed
such that no further processing is required. If the medical insurance
claim data submitted to the medical insurance claim processor by
terminal 101 has not been correctly processed by the medical insurance
claim processor 102 in accordance with the predetermined processing
rules, processor 112 generates comparison data to indicate that
the claim data has been incorrectly processed and identify the specific
processing errors. The comparison data may be stored in storage
111, and/or optionally sent to a printer 103 or display device 104,
such as a monitor, coupled to terminal 101.
[0049] The predetermined processing rules utilized by processor
112 to perform its comparison of the stored medical insurance claim
data and the processed claim data will now be described in further
detail. As described above in the Background section, a health care
provider negotiates a contract or other binding agreement with a
medical insurance company that dictates the terms and conditions
under which the medical insurance company will pay the health care
provider for rendering health care services to patients insured
by the insurance company. For example, under terms of one such contract,
the insurance company may agree to award a certain number of value
points for each examination and/or procedure performed and each
supply used by the health care provider (for example, using the
AMA published codes and point values) and then to convert the value
points into a dollar value using a conversion factor. This value
point and conversion factor claim processing system comprises the
predetermined processing rules used by processor 112 to verify the
accurate processing of medical insurance claim data submitted by
the health care provider to the medical insurance company.
[0050] Notably, any type of claim processing and payment system
may be programmed into the health care provider terminal 101 within
the scope of the present invention.
[0051] The comparison process performed by processor 112 will now
be described in detail with reference to FIG. 2. First, processor
112 receives processed claim data from transmitter/receiver 113
(step 201). Processor 112 then identifies the processed claim data
by retrieving from the processed claim data identification data,
such as a claim identification code or a patient identification
code and date of service code (step 202). Processor 112 then accesses
the corresponding stored medical insurance claim data stored in
storage 111 using the identification data retrieved from the processed
claim data (step 203). Processor 112 then compares the stored medical
insurance claim data with the processed claim data as follows. First,
processor 112 identifies the first code (e.g., an examination, procedure
or supply code) listed in the stored claim data (step 204A). Processor
112 then checks the processed claim data to determine whether the
first processing code is included in the processed claim data (step
204B). If the processed data does not include the first code in
the stored claim data, processor 112 stores the omitted first code
in storage 111 as an omitted code (step 204C). If the processed
data does include the first code, processor 112 checks to see whether
the monetary reimbursement/payment amount awarded by the insurance
company for the first code in the processed claim data is the correct
amount based upon the predetermined processing rules stored in storage
111 (step 204D). If the monetary award awarded for the first code
is correct, processor 112 stores the first code in storage 111 as
a correctly processed code (step 204E). If the monetary amount awarded
for the first code is not correct, processor 112 stores the first
code in storage 111 as an incorrectly processed code. Processor
112 also stores in storage 111 the correct amount of payment associated
with the first code under the predetermined processing rules and/or
the difference between the correct amount of payment and the amount
actually paid by the medical insurance claim processor 102 (step
204F).
[0052] Processor 112 then searches the stored medical insurance
claim data retrieved from storage 111 for the next code (e.g., examination,
procedure or supply code) and repeats the process described above
with reference to steps 204A-F until all codes in the stored medical
insurance claim data have been processed and identified as correctly
processed, omitted, or incorrectly processed. When no additional
codes are found in the stored medical insurance claim data, the
comparison process is complete (step 204G).
[0053] Processor 112 then generates and stores in storage 111 comparison
data that indicates which of the codes listed in the medical insurance
claim data have been correctly processed, which have been omitted,
and which have been incorrectly processed as described above with
reference to steps 204A-E (step 205).
[0054] For example, a medical insurance claim may be entered by
a health care provider into terminal 101 as follows:
Claim ID ABCD
Date of Service Oct. 1, 2004
Examination Code 1
Diagnostic Code 1
[0055] Procedure Code 1 [0056] Supply Code 1
[0057] Procedure Code 2
[0058] Procedure Code 3
Diagnostic Code 2
[0059] Procedure Code 1
[0060] Procedure Code 2 [0061] Supply Code 1 Corresponding processed
claim data received from medical insurance claim processor 102 may
be received as follows: Claim ID ABCD Date of Service Oct. 1, 2004
Examination Code 1--$50 Diagnostic Code 1
[0062] Procedure Code 1--$25 [0063] Supply Code 1--$6
[0064] Procedure Code 2--$10
Diagnostic Code 2
[0065] Procedure Code 1--$15
[0066] Procedure Code 2--$3
[0067] In response to this processed claim data, processor 112
may generate the following comparison data:
Claim ID ABCD
Examination Code 1--$50 correct
Diagnostic Code 1
[0068] Procedure Code 1--$25 correct [0069] Supply Code 1--$6 correct
[0070] Procedure Code 2--$10 incorrect (-$5)
[0071] Procedure Code 3--omitted
Diagnostic Code 2
[0072] Procedure Code 1--$15 correct
[0073] Procedure Code 2--$3 incorrect (-$8) [0074] Supply Code
1--omitted This comparison data indicates that two procedure codes
have been incorrectly processed such that the insurance company
still owes a total of $13 for these two procedures. Additionally,
one procedure code and one supply code were omitted and still need
to be processed and paid by the insurance company.
[0075] Alternatively, processor 112 may generate the following
comparison data in which only the incorrect and omitted data are
included:
Claim ID ABCD
Diagnostic Code 1
[0076] Procedure Code 2--$10 incorrect (-$5)
[0077] Procedure Code 3--omitted
Diagnostic Code 2
[0078] Procedure Code 2--$3 incorrect (-$8) [0079] Supply Code
1--omitted
[0080] The comparison data may be displayed on a display 103, such
as a computer monitor (optional step 206); printed using a printer
104 (optional step 207); or otherwise stored, transmitted, etc.
as is useful to the health care provider.
[0081] Additionally, in accordance with an alternative embodiment
of the present invention, the comparison data is used by processor
112 to create revised claim data (optional step 208). When the comparison
data indicates that there are incorrectly processed or omitted codes
in the processed claim data, processor 112 creates revised claim
data using the identification data from the processed claim data
and/or stored claim data. The revised claim data also includes omitted
codes from the stored medical insurance claim data and incorrectly
processed codes. The difference between the amount paid and the
amount due to the health care provider under the predetermined processing
rules may also be included in the revised claim data.
[0082] For example, in response to the comparison data shown above,
the following revised claim data may be generated:
Claim ID ABCD--REVISED
Date of Service Oct. 1, 2004
Diagnostic Code 1
[0083] Procedure Code 2--Paid in part--$5 owed
[0084] Procedure Code 3--Process and pay in full
Diagnostic Code 2
[0085] Procedure Code 2--Paid in part--$8 owed [0086] Supply Code
1--Process and pay in full
[0087] The revised claim data is stored by processor 112 in storage
111 (optional step 209). The revised claim data is also transmitted
by transmitter/receiver 113 to the medical insurance claim processor
102 for subsequent processing (optional step 210). Processed revised
claim data received by the health care provider terminal 101 from
the medical insurance claim processor 102 is processed in the same
way as all other processed claim data is processed as described
above with reference to FIG. 2.
[0088] According to an alternative embodiment of the present invention,
processor 112 may further be programmed to notify the health care
provider when medical insurance claim data transmitted to medical
insurance claim processor 102 has not been processed within a predetermined
period of time. For example, in one embodiment of the present invention
illustrated in FIG. 3, processor 112 of health care provider terminal
101 is programmed to notify the health care provider of any medical
insurance claim data transmitted to medical insurance claim processor
102 for which processed claim data has not been received within
a predefined period of time from the date of transmission to medical
insurance claim processor 102. In order to accomplish this function,
medical insurance claim data entered into terminal 101 and stored
in storage 111 is assigned a date stamp indicating the date on which
the medical insurance claim data is transmitted to medical insurance
claim processor 102 (step 301). Similarly, revised claim data may
be assigned a date stamp indicating the date on which the revised
claim data is transmitted to medical insurance claim processor 102.
In accordance with this embodiment of the present invention, medical
insurance claim data and revised claim data for which processed
claim data has not yet been received is stored as pending claim
data in storage 111. Once corresponding processed claim data is
received from medical insurance claim processor 102, the stored
medical insurance claim data is no longer stored as pending claim
data.
[0089] Periodically (for example, daily, weekly or otherwise as
desired by the health care provider), processor 112 retrieves date
stamp data from the pending claim data stored in storage 111 (step
302) and compares the date stamp data of each pending claim with
the current date (step 303). If the difference between the date
stamp date of a pending claim and the current date is more than
a defined number of days (e.g., 60, 90 or any number of days as
desired by the health care provider), processor 112 then generates
notification data to indicate that the pending claim has been pending
for more than the defined period of time (step 304). If the amount
of time pending is less than the defined amount of time, the pending
claim data remains stored in storage 111 and no notification data
is generated (step 305).
[0090] Notification data may be optionally displayed on a monitor
(optional step 306) or printed (optional step 307). Processor 112
may also be programmed to automatically retransmit claims that have
been pending for more than the defined period of time to the medical
insurance claim processor 102 (optional step 308). Medical insurance
claim data retransmitted in accordance with this embodiment of the
present invention include data indicating that the medical insurance
claim data is a resubmission of claim data transmitted to the medical
insurance claim processor 102 at an earlier date.
[0091] In addition to the point values and conversion factors stored
in storage 111 as predetermined processing rules, other processing
rules may be stored. For example, in accordance with an alternate
embodiment of the present invention, additional processing rules
are programmed into terminal 101 to indicate whether the diagnostic
codes, procedure codes, and supply codes included in medical insurance
claim data entered into terminal 101 are correctly associated. As
described in the Background section above, each diagnostic code
is defined with certain associated procedure codes, and each procedure
code is defined with certain associated supply codes. If the procedural
or supply codes are not correctly entered, then the claim may be
returned to the health care provider terminal 101 for correction
without being processed by medical insurance claim processor 102.
[0092] To avoid this rejection of medical insurance claim data,
processor 112 may process medical insurance claim data prior to
its transmission to the medical insurance claim processor 102 as
described with reference to FIG. 4. Processor 112 receives medical
insurance claim data input into terminal 101 (step 401). Processor
112 then identifies a first diagnostic code from the medical insurance
claim data (step 402). Next, processor 112 identifies all procedure
codes and supply codes associated with the first diagnostic code
(step 403) in the medical insurance claim data. Processor 112 then
compares the first diagnostic code with the associated procedure
codes and compares the procedure codes with the associated supply
codes using the predetermined processing rules to determine whether
the diagnostic codes, procedure codes, and supply codes are properly
associated (step 404). If the first diagnostic code and corresponding
procedure and supply codes are properly associated in accordance
with the predetermined processing rules, processor 112 identifies
the next diagnostic code from the medical insurance claim data and
repeats the process in steps 402-404 described above until all diagnostic
codes, procedure codes, and supply codes have been checked. If all
diagnostic codes, procedure codes, and supply codes in the medical
insurance claim data are properly associated, processor 112 stores
the medical insurance claim data (step 405) and transmits the data
to the medical insurance claim processor 102 via transmitter 113
(step 406). If any of the diagnostic codes, procedure codes and
supply codes in the medical insurance claim data are not properly
associated in accordance with the predetermined processing rules,
processor 112 generates and stored notification data concerning
this error and holds the medical insurance claim data in storage
111 until the claim data is corrected (step 407). Notification data
may be displayed on display 103 or printed on printer 104 as desired
by the health care provider.
[0093] For example, medical insurance claim data may be entered
into terminal 101 as follows:
Claim ID ABCD
Date of Service Oct. 1, 2004
Examination Code 1
Diagnostic Code 1
[0094] Procedure Code 1
[0095] Procedure Code 2 [0096] Supply Code 1
[0097] Procedure Code 3 [0098] Supply Code 1
[0099] Procedure Code 4
Diagnostic Code 2
[0100] Procedure Code 1
[0101] Procedure Code 2
[0102] Procedure Code 3 [0103] Supply Code 1 Diagnostic Code 3
[0104] Procedure Code 1
[0105] Procedure Code 2
[0106] Corresponding notification data generated by processor 112
may be shown as follows:
Claim ID ABCD
Date of Service Oct. 1, 2004
Examination Code 1--valid
Diagnostic Code 1
[0107] Procedure Code 1--valid
[0108] Procedure Code 2--valid [0109] Supply Code 1--valid
[0110] Procedure Code 3--not valid [0111] Supply Code 1--not valid
[0112] Procedure Code 4--not valid
Diagnostic Code 2
[0113] Procedure Code 1--valid
[0114] Procedure Code 2--valid
[0115] Procedure Code 3--valid [0116] Supply Code 1--not valid
Diagnostic Code 3
[0117] Procedure Code 1--valid
[0118] Procedure Code 2--not valid
[0119] This notification data indicates that two of the procedure
codes and one supply code entered under Diagnostic Code 1, one supply
code entered under Diagnostic Code 2, and one of the procedure codes
entered under Diagnostic Code 3 are not allowable under the predetermined
processing rules and require correction before the medical insurance
claim data will be transmitted to the medical insurance claim processor.
[0120] A method for verifying the accurate processing of medical
insurance claim data in accordance with the present invention will
now be described with reference to FIG. 5. In step 501, medical
insurance claim data is input into a health care provider terminal.
The medical insurance claim data is stored (step 502) and transmitted
to a medical insurance claim processor (step 503). The health care
provider terminal receives processed claim data from the medical
insurance claim processor (step 504) and compares the processed
claim data with the stored medical insurance claim data in accordance
with the comparison process described in steps 204A-F described
above with reference to FIG. 2 (step 505). The health care provider
terminal then generates comparison data as described above with
reference to step 205 of FIG. 2 (step 506). The health care provider
terminal may display (optional step 507) or print (optional step
508) the comparison data. In addition, the health care provider
terminal may optionally generate revised claim data as described
in detail above with reference to step 208 of FIG. 2 (optional step
509) and store and transmit the revised claim data to the medical
insurance claim processor as described above with reference to steps
209-210 of FIG. 2 (optional steps 510 and 511).
[0121] While the present invention has been particularly described
with reference to the preferred embodiments, it should be readily
apparent to those of ordinary skill in the art that changes and
modifications in form and details may be made without departing
from the spirit and scope of the invention. It is intended that
the appended claims include such changes and modifications. |