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Insurance Abstract
The present invention relates to methods and systems for automated
processing and assessment of an insurance disclosure. One embodiment
of the invention can comprise an automated disclosure processing
application engine. The automated disclosure processing application
engine can be adapted to receive health care-related information.
Health care-related information, also known as a "disclosure,"
can include, but is not limited to, a medical claim, a precertification
notice, prescription drug history, or any other information related
to a medical or insurance claim for reimbursement or payment. Health
care-related information can be received at any time, such as in
real time, a predefined basis, daily, or on a less or more frequent
basis. Health care-related information can be stored in a database,
such as a AWAC.RTM. database. A portion of the health care-related
information can be compared to at least one financial parameter.
A portion of the health care-related information can also be compared
to at least one clinical parameter. An output can be generated based
in part on either the comparison with at least the financial parameter
or the clinical parameter.
Insurance Claims
1. A method for processing and assessment of an insurance disclosure
via a network comprising: receiving health care-related information
from at least one data source; comparing a portion of the health
care-related information to at least one financial parameter; comparing
a portion of the health care-related information to at least clinical
parameter; and based at least in part on the comparison of the health
care-related information to at least a financial parameter or clinical
parameter, generating an output providing selected health care-related
information.
2. The method of claim 1, wherein receiving health care-related
information from at least one data source, comprises: receiving
health care-related information from at least one disclosure source;
and storing the health care-related information in at least one
data storage device.
3. The method of claim 1, wherein the at least one data source
includes data comprising at least one of the following: medical
claim information, precertification data, prescription drug history,
medical record information, medical or diagnostic test results,
information associated with a medical insurance claim for reimbursement,
information associated with a medical insurance claim for payment,
or information associated with at least one medical insurance claim.
4. The method of claim 1, wherein generating an output providing
selected health care-related information comprises: filtering the
health care-related information against at least financial parameter
or clinical parameter.
5. The method of claim 1, wherein the financial parameter comprises
at least one of the following: a limit; a value; a range of values;
or a range of limits.
6. The method of claim 1, wherein the clinical parameter comprises
at least one of the following: an ICD, CPT, HCPC, DRG, alpha descriptor,
outlier, or any combination thereof.
7. The method of claim 1, further comprising: receiving a request
for a comparison from at least one client.
8. The method of claim 7, wherein receiving a request for a comparison
from at least one client comprises: receiving an instruction to
provide comparative information associated with at least one financial
parameter; and receiving an instruction to provide comparative information
associated with at least one clinical parameter.
9. The method of claim 1, wherein generating an output providing
selected health care-related information comprises providing a graphical
user interface capable of displaying selected health care-related
information.
10. A system for providing processing and assessment of an insurance
disclosure via a network comprising: an automated disclosure processing
application engine configured to receive health care-related information
from at least one data source; compare a portion of the health care-related
information to at least one stop loss threshold; compare a portion
of the health care-related information to at least one code of concern;
and based at least in part on the comparison of the health care-related
information to at least a financial parameter or clinical parameter,
generate an output providing selected health care-related information.
11. The system of claim 10, further comprising: a financial parameter
module configured to assess health care related data based on at
least one predefined financial parameter.
12. The system of claim 10, further comprising: a clinical parameter
module configured to assess health care-related data based on at
least one predefined clinical parameter.
13. The system of claim 10, further comprising: a report module
configured to: prepare a summary report, wherein the summary report
comprises selected health care-related information; and transmit
the summary report to a client.
14. The system of claim 10, wherein receive health care-related
information from at least one data source comprises: receiving health
care-related information from at least one disclosure source; and
storing the health care-related information in at least one data
storage device.
15. The system of claim 10, wherein the at least one data source
includes data comprising at least one of the following: medical
claim information, precertification data, prescription drug history,
medical record information, medical or diagnostic test results,
information associated with a medical insurance claim for reimbursement,
information associated with a medical insurance claim for payment,
or information associated with at least one medical insurance claim.
16. The system of claim 10, wherein generate an output providing
selected health care-related information comprises: filtering the
health care-related information against at least one financial parameter
or clinical parameter.
17. The system of claim 10, wherein the financial parameter comprises
at least one of the following: a limit; a value; a range of values;
or a range of limits.
18. The system of claim 10, wherein clinical parameter comprises
at least one of the following: an ICD, CPT, HCPC, DRG, alpha descriptor,
outlier, or any combination thereof.
19. The system of claim 10, wherein the automated disclosure processing
application engine is further configured to: receive a request for
a comparison from at least one client.
20. The system of claim 10, wherein receive a request for a comparison
from at least one client comprises: receiving an instruction to
provide comparative information associated with at least one financial
parameter; and receiving an instruction to provide comparative information
associated with at least one clinical parameter.
21. The system of claim 10, wherein generate an output providing
selected health care-related information comprises providing a graphical
user interface capable of displaying selected health care-related
information.
Insurance Description
RELATED APPLICATION
[0001] This application claims priority to U.S. Provisional Ser.
No. 60/728,163, entitled "SYSTEMS AND METHODS FOR AUTOMATED
PROCESSING AND ASSESSMENT OF AN INSURANCE DISCLOSURE," filed
Oct. 19, 2005, the contents of which are hereby incorporated by
reference.
FIELD OF THE INVENTION
[0002] The invention is generally directed to systems and methods
for processing insurance information. More particularly, the invention
relates to systems and methods for automated processing and assessment
of an insurance disclosure via a network.
BACKGROUND
[0003] The health care industry is often criticized for the increasing
costs of medical care, products, and services. One reason for the
increasing cost of medical care, products, and services is the administrative
burden of the increasing amount of paperwork that may be needed
to support the decision making process of stakeholders. This process
can begin long before an insured seeks health care, and may start
before an individual or employer purchases health insurance. Typically,
the process begins when an estimate of the utilization of medical
care, products, and services is calculated by actuaries or underwriters
who may assess the risks of individual members of a health care
plan. At some point, an insured, or a provider on the insured's
behalf, may file a claim for medical care, products, or services
for insurance reimbursement. An administrator of the plan may then
ensure that the reimbursement expenses are covered by the plan,
and can make appropriate payments to the provider. Various information
can be supplied to the insurance company and/or reinsurance carrier
for purposes including, but not limited to, reimbursement, audit,
setting reserves, and assessing risks on an ongoing basis as well
as to set premiums for a subsequent plan year.
[0004] Conventional administrative methods can involve periodic
transmission of individual claims data, prescription data or precertification
data throughout a plan year, or upon request by the insurance, managing
general underwriter or reinsurance carrier of summary information
via paper reports. Such data is generally transmitted in instances
when a catastrophic event such as an expensive diagnosis occurs,
when there is a large claim such as a relatively expensive claim,
or at a predefined time prior to renewal, such as 90 days prior
to expiration of a plan or policy. These conventional processes
can be time consuming, such as when reimbursement of a claim paid
by an employer is delayed. In other instances, these processes can
be expensive, such as when skilled labor is employed to determine
which insured's files to review and to further determine which data
in files may be relevant or otherwise important.
[0005] In other instances, conventional processes can lead to incorrect
or incomplete data. Sometimes, there may be an immediate need for
information, and errors by personnel in collecting and/or reporting
information may result. In some instances, relatively important
factual information may be missing or incomplete, which can result
in subsequent requests for information. In any instance, missing
or incomplete data can result in errors in setting reserves under
a particular plan, or may result in inaccurate underwriting of risk
for a renewal plan.
[0006] Therefore a need exists for improved systems and processes
to process and assess an insurance claim or disclosure via a network.
SUMMARY OF THE INVENTION
[0007] Accordingly, systems and processes according to various
aspects and embodiments according to the invention address at least
some or all of these issues and combinations of them. They do so
at least in part by automating processing and assessment of an insurance
disclosure via a network.
[0008] Specifically, embodiments of the invention can provide a
subscriber, such as an insurance underwriter, claims administrator,
managing general underwriter, reinsurance carrier, broker, intermediary,
employer or third party insurance plan administrator, with information
to make decisions related to insuring consumers and assessing risks
associated with insuring consumers. Embodiments of the invention
can operate via a network and can receive consumer health care-related
information, such as medical claim information, precertification
data, prescription drug history, medical record information, and
medical or diagnostic test results, in the form of an "insurance
disclosure." Subscribers can define parameters such as financial
parameters (by way of example, but not limited to financial stop
loss or aggregate claims incurred or paid) or clinical parameters
(by way of example, but not limited to, clinical codes of concern,
ICD9, CPT, HCPCs, DRG codes or drugs) or combinations of financial
and clinical parameters (e.g., ICD9 code 178.15 if the claim or
total claims incurred total over $75,000 or total claims paid total
over $40,000 in the current plan year). Some or all of these parameters
can be stored by an embodiment of the invention to process the consumer
health care information or insurance disclosure, including associated
health care provider information and any insurance disclosure requirements.
Embodiments of the invention can also send at least one customized
report to a subscriber via email or other modes of communication
with a list of insured groups, insureds or claim assessments of
an insurance disclosure via a network. Through the network, subscribers
can obtain or view the report via an Internet or web browser interface.
Via the interface, a subscriber can drill down and analyze the report,
including viewing some or all additional detail and associated information
for a particular consumer or record.
[0009] One purpose of providing disclosure processing is to provide
subscribers (Carriers, Managing General Underwriters (MGUs), Third
Party Administrators (TPAs), Plan Sponsors, and others) with timely
reports and immediate access to on line information that may impact
their business. One type of report, for instance, is a "stop
loss report." This type of report can provide a daily list
of consumers or insureds who may have exceeded or broken a group-based,
subscriber-established, or otherwise predefined stop loss threshold,
or an insured-based, subscriber-established, or otherwise predefined
stop loss threshold on a daily basis relative to a policy expiration.
[0010] Another type of a report can be a "code of concern
report." This type of report can provide a daily list of consumers
or insureds who may have a subscriber-established ICD (International
Classification of Disease) code, CPT (Current Procedural Technology)
code, or dollar amount (or combination thereof) occurrence relative
to a policy expiration.
[0011] Yet another type of report can be a "customized summary
report." This type of report can summarize some or all information
based at least in part on subscriber-established or other predefined
criteria. Such reports can be generated and/or transmitted on a
regular or predefined basis including, but not limited to, a predefined
interval, date, or date relative to a trigger date or regular, predefined
or custom-defined trigger occurrence in the data or calculated fields
constructed using constants and data.
[0012] One aspect of systems and methods according to various embodiments
of the invention, focuses on a method for processing and assessment
of an insurance disclosure via a network. The method includes receiving
health care-related information from at least one data source. Furthermore,
the method includes comparing a portion of the health care-related
information to at least one financial parameter. Moreover, the method
includes comparing a portion of the health care-related information
to at least one clinical parameter. Further, the method includes
based at least in part on the comparison of the health care-related
information to either a financial parameter or clinical parameter,
generating an output providing selected health care-related information.
[0013] Another aspect of systems and methods according to various
embodiments of the invention, focuses on a system for providing
processing and assessment of an insurance disclosure via a network.
The system includes an automated disclosure processing application
engine. The automated disclosure processing application engine is
configured to receive health care-related information from at least
one data source. Moreover, the automated disclosure processing application
engine is configured to compare a portion of the health care-related
information to at least one financial parameter. Further, the automated
disclosure processing application engine is configured to compare
a portion of the health care-related information to at least one
clinical parameter. Furthermore, the automated disclosure processing
application engine is configured to based at least in part on the
comparison of the health care-related information to either a financial
parameter or clinical parameter, generate an output providing selected
health care-related information
[0014] Aspects, features and advantages of various systems and
processes according to various embodiments of the present invention
can include:
[0015] (1) Providing systems and methods for processing and assessing
an insurance disclosure via a network;
[0016] (2) Providing systems and methods for automatically processing
and assessing an insurance disclosure via a network.
[0017] (3) Providing systems and methods for automating processing
of an insurance disclosure via a network.
[0018] Other aspects, features and advantages will become apparent
with respect to the remainder of this document.
[0019] These example embodiments are mentioned not to limit or
define the invention, but to provide examples of embodiments of
the invention to aid understanding thereof. Example embodiments
are discussed in the Detailed Description, and further description
of the invention is provided there.
BRIEF DESCRIPTION OF THE DRAWINGS
[0020] FIG. 1 illustrates an example flowchart for a method in
accordance with an embodiment of the invention.
[0021] FIGS. 2-4 illustrate examples of login web pages in accordance
with an embodiment of the invention.
[0022] FIGS. 5-7 illustrate examples of folder hierarchy and organization
in accordance with an embodiment of the invention.
[0023] FIG. 8-16 illustrate examples of reports, sub-reports, and
supporting data in accordance with an embodiment of the invention.
[0024] FIGS. 17-18 illustrate examples of web pages associated
with data transfer and storage in accordance with an embodiment
of the invention.
[0025] FIGS. 19-20 illustrate examples of web pages associated
with the formatting and output of reports in accordance with an
embodiment of the invention.
[0026] FIGS. 21-23 illustrate examples of web pages associated
with shadowing a user or subscriber in accordance with an embodiment
of the invention.
[0027] FIG. 24 illustrates an example system in accordance with
an embodiment of the invention.
DETAILED DESCRIPTION
[0028] Referring now to the drawings in which like numerals indicate
like elements throughout the several figures, FIG. 1 below illustrates
a process flow 100 of information during the processing and assessment
of an insurance disclosure via a network in accordance with an embodiment
of the invention.
[0029] The process 100 can permit a user or a subscriber, such
as an insurance carrier, third party plan administrator, or another
entity, to obtain processed information to make a strategic decision
that may otherwise be made with possibly inaccurate or partial data.
The process 100 can assist a user or subscriber in filtering information
by providing the user or subscriber with the ability to process
data using predefined or tailored data thresholds and parameters.
These thresholds and parameters can permit a user or subscriber
to acquire data needed to address insurance activity and make more
accurate risk assessments.
[0030] The process 100 begins at block 102. In block 102, health
care-related information is received by a subscribing entity, such
as a user or subscriber. Health care-related information, also known
as a "disclosure," can include, but is not limited to,
medical claim information, precertification data, prescription drug
history, medical record information, medical or diagnostic test
results, or any other information related to a medical or insurance
claim for reimbursement or payment. Health care-related information
can be received at any time, such as in real time, a predefined
basis, daily, or on a less or more frequent basis.
[0031] Block 102 is followed by block 104, in which the health
care-related information is stored in a database. In this embodiment,
the health care-related information is scrubbed, mapped, imported,
and stored in a database, such as 2420 in FIG. 24, a AWAC.RTM. database,
or other data storage device.
[0032] Block 104 is followed by block 106, in which a portion of
the health care-related information is compared to at least financial
parameter. In this embodiment, the health care-related information
can be processed by an automated disclosure processing application
program, such as 2414 in FIG. 24. A financial parameter can include,
but is not limited to, any limit or value as incurred, paid, or
otherwise projected to be paid and defined by a group, user, subscriber,
insurer, or any other entity. In some instances, a financial parameter
can include a band or range of limits or values.
[0033] Block 106 is followed by block 108, in which a portion of
the health care-related information is compared to at least one
clinical parameter. In this embodiment, the health care-related
information can be processed by an automated disclosure processing
application program, such as 2414 in FIG. 24. A clinical parameter
can include, but is not limited to, an ICD9 (International Classification
of Disease) code, CPT (Current Procedural Technology) code, HCPC
(Healthcare Common Procedure Code), DRG (Diagnostic Related Group)
code, alpha descriptor, code of concern, code, drug type or name,
an outlier with at least one certain disease or physical characteristic
description, or any combination thereof.
[0034] Block 108 is followed by block 110, in which an output is
generated based in part on either the comparison with the financial
parameter or the clinical parameter. In the embodiment shown, an
automated disclosure processing application program, such as 2414
in FIG. 24, can facilitate the display of an output via a client
device, such as 2402a in FIG. 24, or associated display device by
transmitting a suitable signal to the client device 2402a or associated
display device.
[0035] In one embodiment, generating an output includes providing
a graphical user interface capable of displaying selected cost information
and provider information.
[0036] The process 100 ends at block 110.
[0037] In one aspect, medical claims, precertification notices
and/or prescription drug history can be received at a database,
such as an AWAC.RTM. database, on an interval basis (daily or less
frequently). The data can be scrubbed, mapped, imported, and stored
in a database, such as 2420 in FIG. 24, an AWAC.RTM. database, or
other data storage device. A preliminary claims analysis can be
performed with data from the database 2420, AWAC.RTM. database,
or other data storage device.
[0038] In another aspect, some of all of the following steps can
be performed in conjunction with or as part of a method for processing
and assessment of an insurance disclosure, including assessing a
data load for one or more financial parameters or "stop loss"
subscriber defined parameters, and assessing a data load for one
or more clinical parameters or "codes of concern" subscriber
defined parameters. Either or both of these processes can respectively
identify insurance disclosures or claims that meet one or more financial
parameter or stop loss and/or clinical parameter or code of concern
selection criteria described in the sections below.
[0039] For example, a process to assess a data load for group financial
parameters or stop loss can be implemented as follows: [0040] Select
all insurance claims for an insured in the current load where we
have the group's policy period and Stop Loss threshold information
defined. The insurance claim is for an Insured, who is in a Group,
which is self-administered or under a TPA, which is sponsored by
a MGU or Carrier. [0041] FOR EACH such insurance claim: [0042] Calculate
Sum_Of_Claims (Charge & Paid) for the Patient tied to this claim
for all his claims in the policy year (group-based, if not insured-based)
[0043] IF Sum_of_Claims for patient is greater than a subscriber
defined percentage (e.g., 50%, 75%, 100%) of the Stop Loss value
(Group-based, if not insured-based) then [0044] Record the following
information: [0045] Carrier, TPA, GroupNumber, PolicyBeginDate,
[0046] PolicyEndDate, [0047] PatientInsuranceNumber, PatientName,
[0048] PercentageThresholdBroken (Charge & Paid), [0049] LoadDate,
LoadID, AWAC_ClaimID, [0050] ICN, FirstDOS, LastDOS, [0051] ChargeDate,
ChargeAmt, SumChargeToDate [0052] PaidDate, PaidAmt, SumPaidToDate
[0053] Breaking a percentage of the Stop/Loss threshold is only
recorded the first time that percentage is broken for a patient.
[0054] END IF [0055] END FOR
[0056] In another example, a process to check clinical parameters
such as Check Load For Codes Of Concern can be implemented as follows:
[0057] Select all insurance claims, precertifications, and treatments
for a Subscriber in the current load that have ICD9 codes and/or
CPT codes and/or dollar amounts (or combinations there of) that
match a list of subscriber-defined Codes of Concerns for a specific
subscriber. The insurance claim, precertification, or treatment
is for an Insured, who is in a Group, which is self-administered
or under a TPA, which is sponsored by a MGU or Carrier. [0058] FOR
EACH such claim: [0059] Calculate Sum_Of_Claims (Charge & Paid)
for the Patient tied to this claim for all his claims in the policy
year (group-based) [0060] Calculate Count_Of_Codes for the Patient
tied to this claim for all his claims in the policy year (group-based)
that contains the Code of Concern [0061] Record the following information:
[0062] Carrier, TPA, GroupNumber, PolicyBeginDate, PolicyEndDate,
[0063] PatientInsuranceNumber, PatientName, [0064] CodeOfConcern,
[0065] LoadDate, LoadID, AWACClaimID, [0066] ICN, FirstDOS, LastDOS,
DaysToPolicyEndDate, [0067] ChargeAmt, PaidAmt, [0068] SumChargeToDate,
SumPaidToDate, CountOfCodesToDate, [0069] MinFirstDOS, MaxLastDOS
[0070] A Code of Concern is only recorded the first time it appears
in a claim in a policy year for a patient. [0071] END FOR
[0072] In another aspect, once disclosure processing is completed,
one or more customized reports can be sent to inform subscribers
of the previous day's insurance claims that have, for instance,
broken or exceeded the stop loss thresholds and that contain or
otherwise include codes of concern.
[0073] In another aspect, one or more reports, such as a summary
report, can be generated with predefined or subscriber-selected
data. For instance, a subscriber can select particular data to include
in a report, or may select certain sorting or search criteria to
select particular data to include in a report.
[0074] In yet another aspect, one or more reports can be generated
and transmitted on a regular or predefined basis. For instance,
a report can be generated and sent on a regular basis, such as every
30, 60, and 90 days after a certain date. In another instance, a
report can be generated and sent at other intervals, dates, or dates
relative to certain events or trigger events.
[0075] For example, a process for generating a report such as a
"Report Control" can be implemented as follows: [0076]
A report control table is populated at the end of the day based
on the reports that need to be run for the subscribers that have
subscribed to the Disclosure Reporting service. The control table
provides parameters for the reports to run. [0077] Code of Concern
report [0078] Stop Loss reports [0079] The reports are scheduled
to run for each subscriber daily. The parameters drive whether the
reports include the period summary portions of the report.
[0080] In yet another aspect, one or more summary reports can be
scheduled to run at certain intervals relative to the policy expiration,
where the periods are subscriber defined.
[0081] In another aspect, a web based/browser based window or other
graphical user interface associated with an application program
can permit real time data viewing and manipulation that can be user
or subscriber defined. For example, such a web based/browser based
window or other graphical user interface can be associated with
an automated disclosure processing application program, such as
2414 in FIG. 24, and the window can be displayed via a client device,
such as 2402a in FIG. 24, for viewing by a user, such as 2412a in
FIG. 24. Data, such as information associated with one or more insurance
claims that exceed or meet a predefined financial parameter such
as a stop loss threshold and/or at least one clinical parameter
such as a code of concern, can be viewed, manipulated and/or selected
by the user 2412a via the window or other graphical user interface.
[0082] In another aspect of the invention, various web pages or
other user interfaces can be implemented or otherwise facilitated
by embodiments of the invention. For example, such web pages or
other user interfaces can be associated with an automated disclosure
processing application program, such as 2414 in FIG. 24, and the
web pages or other user interfaces can be displayed via a client
device, such as 2402a in FIG. 24, for viewing by a user, such as
2412a in FIG. 24. Data, such as information associated with one
or more insurance claims that exceed or meet a predefined financial
parameter such as a stop loss threshold and/or at least one clinical
parameter such as a code of concern, can be viewed, manipulated
and/or selected by the user 2412a via the web pages or other user
interfaces.
[0083] Some or all of the processes and aspects described above
can be incorporated into one or more application programs, such
as an application program known as the iKNOW.TM. application suite
to be distributed by Innovative Health Strategies, Inc. of Augusta,
Ga. One embodiment of an application program in accordance with
the invention is described below.
[0084] An application program in accordance with an embodiment
of the invention, such as the iKNOW.TM. application suite, can provide
information in the field of health care. By accumulating and presenting
information, the iKNOW.TM. application suite can provide a relatively
secure vehicle for subscribers to make strategic decisions that
they may otherwise make with possibly inaccurate or partial data.
The iKNOW.TM. application suite can be directed towards assisting
users or subscribers with tailored data thresholds and parameters.
These thresholds can allow users or subscribers to acquire some
or all of the critical data needed to address insurance activity
and make relatively more accurate risk assessments with respect
to particular situations.
[0085] The iKNOW.TM. application suite can be implemented, for
example, in conjunction with the Citrix Metaframe Access Suite,
an advanced remote desktop technology, and Crystal Reports Enterprise
architecture distributed by Business Objects. This example implementation
can allow for enterprise level report customization, capabilities
and features required for or utilized with the robust development
standards the iKNOW.TM. application suite may bring to the health
care industry. The data can reside in, for instance, a custom developed
Oracle database which may provide suitable performance and reliability.
[0086] The iKNOW.TM. application suite can be accessed by one or
more client devices via a web portal, such as the AWAC Web Portal.
Access to the portal can occur through 128 bit secure sockets layer
HTTPS communication via certificates provided by a web site certification
entity, such as Verisign, Inc. By way of example, the web pages
below demonstrate a view of an authentication phase, reporting user
interface, navigation steps, and reporting features of the iKNOW.TM.
application suite.
[0087] In one embodiment, some or all of the information processing
can be performed by a Citrix Metaframe Server farm, thus reducing
some or all of the need for processing information via a user's
client or associated client hardware. This configuration can allow
for maintaining a homogenous user experience across a multi-platform
client base. This infrastructure landscape can also provide for
enhanced on-demand search and reporting features that otherwise
would not be possible because of the transmission of relatively
large data sets across the Internet or a network, and the processing
performed by the client or associated client hardware to sort and
present the data. The iKNOW.TM. application suite can be published
via a thin-client architecture. All application changes can be dynamically
pushed to one or more clients, and little or no user intervention
may be needed in regards to in house upgrades and customizations
to the iKNOW.TM. application suite reports.
[0088] In this embodiment, an AWAC Web Portal can provide a user
or subscriber with an initial point of access to the iKNOW.TM. application
suite and associated functionality. The user or subscriber can be
required to present proper authentication in order to gain access
to the AWAC Web Portal. The authentication step can be secured and,
in some instances, may not pass credentials in plain text across
the Internet or network. Once the user or subscriber has been authenticated
by the AWAC Web Portal, the user or subscriber can access, for example,
a web page such as a home or introductory page described in more
detail below.
[0089] Communication between the website and the user or subscriber
can be secured with, for example, 128 bit level encryption. Once
a user or subscriber is authorized, the user or subscriber can access
or otherwise view one or more web pages described as follows.
[0090] In one embodiment, an initial web page such as a login page
illustrated as 200 in FIG. 2 can be accessed. A user or subscriber
can be prompted for a separate set of credentials to gain access
to a dynamically published application set defined by the user's
or subscriber's group access level associated with a user or subscriber
login account. As shown in FIG. 3, the user or subscriber can then
select an iKNOW.TM. icon, for example, displayed on the webpage
to gain access to the iKNOW.TM. application suite and associated
functionality. Furthermore, double-clicking the iKNOW.TM. icon can
initiate, for example, a Citrix Server connection to facilitate
delivering some or all of the functionality of the iKNOW.TM. application
suite via logon to an associated Citrix Server Farm. The user or
subscriber can be presented with a dialog box, such as an Innovative
Health Strategies internal certification acceptance dialog box,
for communication between the Citrix Server and a server, such as
the iKNOW.TM. application program server. The user or subscriber
can select YES to both dialog boxes in order to proceed to an iKNOW.TM.
webpage home page.
[0091] Continuing from the example above, an iKNOW.TM. login screen,
shown as 400 in FIG. 4, can be displayed and prompt the user or
subscriber for application account information. Entering the authenticated
account information can prompt the display of the main iKNOW screen
at the root user folder level. Each user or subscriber account can
have a root folder. For example, as shown in FIG. 5, the IHS (Innovative
Health Strategies) folder structure 500 can be a common root folder
which is presented to some or all users or subscribers.
[0092] Single-clicking on a particular folder structure can permit
a user or subscriber to drill down into the next or adjacent folder
level structure until reaching a lower level displaying one or more
report objects. The report objects can be parameterized by the account
information provided at login. In some instances, the respective
user or subscriber's account may display appropriate or particularized
data for that user or subscriber's account.
[0093] FIG. 6 illustrates an example series of report objects 600
associated with a folder structure in accordance with an embodiment
of the invention. In this example, report objects can include, but
are not limited to, "Code of Concern Combo", "Code
of Concern DD", "Code of Concern Enterprise", "Code
of Concern Forms", "Stop Loss Combo", "Stop
Loss DD", "Stop Loss Enterprise", and "Stop
Loss Forms". Other embodiments of the invention can include
fewer or greater numbers of report objects as well as different
report objects.
[0094] As shown in FIG. 7, single-clicking on a report object,
such as "Stop Loss Forms" 702, can bring up a cascade
menu selection 704 which can allow users or subscribers to view,
for example, the latest prescheduled report instance, a list of
some or all instances of a report, or a history of some or all reports.
An instance of a report is a data snapshot of a particular point
in time of the report. The user or subscriber can go back in time
as far as the specified control settings may provide, which can
be established by or otherwise modified by the administrator. In
an environment where data may change from day-to-day and a daily
record must or is desired to be maintained, this technology can
provide users or subscribers with suitable control. In some instances,
additional selections may be or may not be granted to users or subscribers
including, but not limited to, scheduling capability, management
of instances, and run on demand. By single-clicking on one of the
instance time-stamps, the application suite can load the corresponding
report instance and stored data set.
[0095] FIG. 8 is an example web page 800 with an example report.
Continuing from the example above in FIG. 7, a user or subscriber
can select from the cascading menu a selection such as "History."
As shown in FIG. 8, a report 802 can provide data, such as historical-type
data 804, or other data, such as responsive to pre-specified control
settings.
[0096] FIG. 9 is an example web page 900 with another example of
a report, such as a stop loss report. As shown in FIG. 9, a report
902 can indicate a particular set of data, such as a data load 904,
and a threshold 906. Output 908 generated by the system, such as
100, in response to a particular threshold, such as 906, can be
displayed in subsequent fields 910, 912, 914 organized by predefined
categories, sub-categories, or other classifications. Other reports
can include other parameters such as a financial and/or clinical
parameters, data loads, thresholds, and outputs in accordance with
an embodiment of the invention.
[0097] In one embodiment, one or more reports can be generated,
and a user or subscriber can navigate through the data of some or
all of the reports. For example, reports, such as a stop loss report
and a disclosure report, and their associated data can be navigated
using associated functionality of the iKNOW.TM. application suite.
Navigation of reports being presented with a web embedded report
viewer or other navigational tool or device, such as a web browser,
can have similar or otherwise common navigational bar icons and
functions. For example, as shown in FIG. 10, navigation drill-down
functionality 1000 can be presented in a left window pane 1002 at
some or all times by default. An icon 1004 located at the upper
left of the report viewer can permit a user or subscriber to turn
this feature off if the user or subscriber requires or needs more
viewable area on the output device or display screen. In this example,
by single-clicking the plus icon 1004 at the left of the hierarchy
structure, the user or subscriber has the ability to drill down
to the bottom level of the structure that meets the search requirements.
The sort groups can represent the hierarchy structure that is displayed
and is automatically coded into the format of the report. In some
instances, no further user or subscriber action may be needed to
enable this feature after the report has been executed or otherwise
generated. The display of the report data set viewable in the right
pane 1006 can follow the corresponding level of hierarchy that the
user or subscriber has currently navigated to.
[0098] In another example, a user or subscriber may also navigate
a report by utilizing the navigation arrows across the top of the
embedded report viewer or other navigational tool or device, such
as a web browser. As shown in FIG. 11, from left to right, example
buttons 1102, 1104, 1106, 1108 for an embedded report viewer may
be as follows: (1) Go to first page of report; (2) Go to previous
page of report; (3) Go to next page of report; and (4) Go to last
page of report. The user or subscriber may also enter a specific
page number in the text window and single-click the "Go to
Specific Page" icon 1110, for instance, portrayed as a sheet
of paper with a red arrow pointing to the right. The user or subscriber
may also enter search criteria in order to navigate or locate specific
points of interest within the report by imputing the parameter and
single-clicking the binoculars-shaped icon 1112, for instance. The
user or subscriber may also adjust the size of the report in the
right pane of the viewer with the percentage drop down tool 1114,
for instance, in the navigational toolbar. Some or all of the functionality
described above is also illustrated in the series of web pages with
other types of reports shown in FIGS. 12, 13, 14, and 15 described
below.
[0099] FIG. 12 illustrates an example of another web page 1200
with another example report in accordance with an embodiment of
the invention. The web page 1200 includes a report 1202 with a navigational
bar 1204 with buttons associated with navigational-type functionality.
As a user or subscriber drills down into a report 1202 or sub-report,
a drop down box 1206 located to the left of the navigational icons
"arrows" 1208 can permit a user or subscriber to jump
between levels of viewer windows showing different reports, sub-reports,
or different aspects of the same report or sub-report. In this manner,
a user or subscriber can jump from one detail level to another detail
level once he or she has drilled past the scope of bottom tier of
the left pane navigation hierarchy. This drop down box 1206 can
provide a user or subscriber the ability to jump back to previous
details, report positions, or to the main report window. To completely
exit a report within the application suite, a user or subscriber
can click a "X" icon located at the top right of the navigational
bar 1204. This action may not close the application suite but it
can permit a user or subscriber to navigate back to the instance
list or report object list depending on whether the user or subscriber
is viewing an on-demand report or a prescheduled instance.
[0100] Each report can have in each record set a group of links
labeled, for instance, in blue color, and named, for instance, "List",
"HCFA", and "UB92". If the data dictates these
parameters, these links can navigate the user or subscriber to the
sub-report. Single-clicking the links can bring sub-reports containing
even greater detail data into the viewer window in either a list
or image format. An example of a list format for a sub-report with
links to various record sets is shown in the web page 1300 shown
in FIG. 13.
[0101] Examples of links can be defined as follows: "List"--Lists
all records matching a particular data element, i.e., claimant;
"HCFA"--Displays all matching data in HCFA (Health Care
Financing Administration) format presented as a printable image
which is populated automatically with the data set; and "UB92"--Displays
all matching data in UB (Universal Billing Code) format presented
as a printable image which is populated automatically with the data
set. The HCFA and UB92 (Uniform Billing Code of 1992) images may
be standardized which can allow for the presentation of the supporting
data in a customary layout.
[0102] FIGS. 14, 15, and 16 illustrate examples of other types
of data that can be provided in accordance with an embodiment of
the invention. FIG. 14 is an example of a report with disclosure-related
data for a particular patient or entity. FIG. 15 is an example of
a payment invoice which may be provided as supporting data in accordance
with an embodiment of the invention. FIG. 16 is an example of a
health insurance claim form which may be provided as supporting
data in accordance with an embodiment of the invention.
[0103] In one embodiment, some or all of the data described above
can be exported by the iKNOW.TM. application suite or associated
functionality. For example in FIG. 17, an icon 1702 located in the
upper left of the navigation toolbar 1704 portrayed as an envelope
with a red arrow pointing down can initiate the export feature within
the iKNOW.TM. application suite. As shown in the window 1706 of
FIG. 17, various business-standard export formats, such as Adobe
PDF, Crystal Reports RPT, Microsoft Word, Microsoft Excel, RTF,
etc., can be available for exporting a report to another application,
program, or computer-readable media. As shown in the webpage 1800
of FIG. 18, a window 1802 can provide a user or subscriber with
a choice of locations during the export process, such as the user
or subscriber's local hard drive, to transmit exported data to.
For quality assurance purposes, the capability of viewing exported
data while still being logged into the iKNOW application suite can
provide an advantage to the user or subscriber. Examples of an Adobe
PDF and a Microsoft Excel formatted report 1900, 2000 are shown
in FIGS. 19 and 20 respectively.
[0104] In another embodiment, a user or subscriber can log off
of the iKNOW.TM. application suite. For instance, a user or subscriber
can exit back to the root folder screen via the "X" icon
in the upper right of the navigational bar where the Logoff link
is presented in the top right. A user or subscriber can single-click
on the Logoff link, which can lead back to the main logon screen.
Single-clicking on the "Close the iKNOW Application" button
can log the user or subscriber off the Citrix Server Farm and return
him or her to the secure portal screen at which time he or she is
provided the ability to enter other published applications or to
exit the secure portal entirely.
[0105] In yet another embodiment, the iKNOW.TM. application suite
can provide shadowing and user training functionality. The infrastructure
can lend itself to the ability for support staff and business staff
whether onsite or offsite to conduct training and shadowing of users
for troubleshooting and/or guidance. Some or all of this interactive
process is displayed in the web pages 2100, 2200, 2300 illustrated
in FIGS. 21, 22, and 23 respectively.
[0106] Other examples of screenshots or user interfaces can be
implemented or otherwise facilitated by an automated disclosure
processing application engine and associated functionality in accordance
with other embodiments of the invention. The above examples are
intended to be by way of example, and are not intended to limit
the scope of the invention.
[0107] FIG. 24 is an illustration of example system components
for a system in accordance with an embodiment of this invention.
The system 2400 shown in FIG. 24 comprises multiple client devices
2402a-n in communication with a server device 2404 over a network
2406. The network 2406 shown can comprise the Internet, an automated
or electronic insurance data network, any other suitable network,
or a combination of such networks. In other embodiments, other networks,
wired and wireless, such as an intranet, local area network, wide
area network, or broadcast network may be used. Moreover, methods
according to the present invention may operate within a single client
or server device. In the example shown, the method 100 illustrated
in FIG. 1 can be implemented by the system 2400.
[0108] Each client device 2402a-n shown in FIG. 24 preferably comprises
a computer-readable medium. The computer-readable medium shown can
comprise a random access memory (RAM) 2408 coupled to a processor
2410. The processor 2410 can execute computer-executable program
instructions stored in the memory 2408. Such processors may comprise
a microprocessor, an Application-Specific Integrated Circuit (ASIC),
a state machine, or other processor. Such processors comprise, or
may be in communication with, media, for example computer-readable
media, which stores instructions that, when executed by the processor,
cause the processor to perform the steps described herein.
[0109] Embodiments of computer-readable media may comprise an electronic,
optical, magnetic, or other storage or transmission device capable
of providing a processor, such as the processor 2410 of client 2402a,
with computer-readable instructions. Other examples of suitable
media may comprise a floppy disk, Compact Disk Read Only Memory
(CD-ROM), magnetic disk, memory chip, Read Only Memory (ROM), Random
Access Memory (RAM), an ASIC, a configured processor, all optical
media, all magnetic tape or other magnetic media, or any other suitable
medium from which a computer processor can read instructions or
on which instructions, code, or other data may be stored. Also,
various other forms of computer-readable media may transmit or carry
instructions to a computer, including a router, private or public
network, or other transmission device or channel, both wired and
wireless. The instructions may comprise code from any suitable computer-programming
language, including but not limited to, for example, C, C++, C#,
Visual Basic, Java, Python, Perl, and JavaScript.
[0110] Client devices 2402a-n may also comprise a number of external
or internal devices such as a magnetic or smart card reader, biometric
data collection devices, mouse, a CD-ROM, a keyboard, a display,
or other input or output devices. Examples of client devices 2402a-n
are card terminals, personal computers, media center computers,
televisions, television set-top boxes, digital assistants, personal
digital assistants, cellular phones, mobile phones, smart phones,
pagers, digital tablets, laptop computers, Internet appliances,
and other processor-based devices. In general, a client device 2402a-n
may be any type of processor-based platform that may be connected
to a network 2406 and that interacts with one or more application
programs. Client devices 2402a-n may operate on any operating system,
such as Microsoft.RTM. Windows.RTM., Macintosh, Unix, or Linux,
capable of supporting one or more client application programs. For
example, the client device 2402a shown comprises a personal computer
executing client application programs, also known as client applications.
The client applications can be contained in memory 2408 and can
comprise, for example, an Internet browser application, and any
other application or computer program capable of being executed
by a client device.
[0111] Each of the client devices 2402a-n can be associated with
a respective subscribing entity or subscriber, such as a carrier,
a managing general underwriter (MGU), a third party administrator
(TPA), or a plan sponsor, shown as users 2412a-n. Through the client
devices 2402a-n, users 2412a-n can communicate over the network
2406 with each other and with other systems and devices coupled
to the network 2406. As shown in FIG. 2, a server device 2404 is
also coupled to the network 2406. For example in the embodiment
shown in FIG. 24, a user 2412a can operate a respective client 2402a
to interact with the server device 2404 and formulate a request
for processing an insurance disclosure. The client 2402a can send
a signal corresponding to the request via the network 2406 to the
server 2404.
[0112] The server device 2404 shown in FIG. 24 comprises a server
executing at least one automated disclosure processing application
program, also known as the automated disclosure processing application
engine 2414 or automated disclosure processing program. Similar
to the client devices 2402a-n, the server device 2404 shown in FIG.
24 comprises a processor 2416 coupled to a computer-readable memory
2418. Server device 2404, depicted in FIG. 24 as a single computer
system, may be implemented as a network of computer processors.
Examples of a server device are servers, mainframe computers, networked
computers, a processor-based device, and similar types of systems
and devices. Client processors 2410 and the server processor 2416
can be any of a number of well known computer processors, such as
processors from Intel Corporation of Santa Clara, Calif. and Motorola
Corporation of Schaumburg, Ill.
[0113] Memory 2418 on the server device 2404 can contain the automated
disclosure processing application engine 2414. An automated disclosure
processing application engine 2414 can comprise a software or hardware
application that is configured to automatically process and assess
an insurance disclosure. In one embodiment, an automated disclosure
processing application engine 2414 can be the IKNOW.TM. software
program to be operated by Innovative Health Strategies, Inc., of
Augusta, Ga. In response to a request for assessment of an insurance
disclosure from a user 2412a operating a client 2402a, the automated
disclosure processing application 2414 shown in FIG. 24 can begin
processing and assessing an insurance disclosure.
[0114] The server device 2404 can also communicate with at least
one database 2420, such as an insurance database, to retrieve and/or
store information associated with processing and assessing an insurance
disclosure. The database 2420 can comprise one or more storage devices
with insurance information, or any other information which can be
used to assess an insurance disclosure.
[0115] Although the processes described herein are described in
relation to the client and server or servers, a client may perform
any or all of the processes described as being performed by a server.
Similarly, a server or servers may perform any or all of the processes
described herein as being performed by a client, although the invention
is not limited to client/server architecture but can run on any
desired topology or architecture as deemed fit for the purposes,
whether existing as of the time of the writing of this document
or thereafter.
[0116] Embodiments of the present invention can comprise systems
having different architecture than that which is shown in FIG. 24.
For example, in some systems according to the present invention,
server device 2404 may comprise a single physical or logical server.
The system 2400 shown in FIG. 24 is merely an example, and is used
as an environment to help explain the example processes and methods
shown in FIG. 1.
[0117] As shown in FIG. 24, an example automated disclosure processing
application engine 2414 can include one or more functional components
to accomplish some or all of the following functionality: assessing
and comparing health care-related data based in part on at least
a financial or stop loss parameter, and assessing and comparing
health care-related data based in part on at least a clinical or
code of concern parameter. Other functions, components, modules,
or sub-components for an automated disclosure processing application
engine 2414 can exist.
[0118] In the embodiment shown in FIG. 24, the automated disclosure
processing application engine 2414 can provide a user interface
for use of the automated disclosure processing application engine
2414 by users 2412a-n via the network 2406. The user interface can
provide users 2412a-n with on-line accessibility to details of a
particular disclosure assessment, and on-line functionality of the
automated disclosure processing application engine 2414. The automated
disclosure processing application engine 2414 can also provide a
user interface for a user 2412a-n to interact with the automated
disclosure processing application engine 2414.
[0119] In one embodiment, an automated disclosure processing application
engine 2414 can include a financial parameter or stop loss module
adapted to assessing and comparing health care-related data based
in part on at least a financial parameter or stop loss parameter.
The financial parameter or stop loss module can collect and utilize
insurance data associated with customers such as businesses, governments,
and other entities. Data can be stored in and/or accessed from one
or more associated databases, such as database 2426, an insurance
database, or any other suitable database or data storage device.
[0120] In yet another embodiment, an automated disclosure processing
application engine 2414 can include a clinical parameter or code
of concern module adapted to assess and compare health care-related
data based in part on at least a clinical parameter or code of concern
parameter.
[0121] In another embodiment, an automated disclosure processing
application engine 2414 can include a customized report module adapted
to facilitate transmission of a customized report to inform a subscriber
of a previous day's claims that have met or exceeded a financial
parameter such as a stop loss threshold and that may contain a clinical
parameter such as one or more codes of concern.
[0122] In another embodiment, an automated disclosure processing
application engine 2414 can include a summary report module adapted
to facilitate transmission of a summary report to a inform a subscriber
at any predefined time, such as scheduling a report at certain intervals
relative to a policy expiration, where the time periods are subscriber
defined.
[0123] Examples of a user interface for a subscriber to interact
with a disclosure processing application program according to an
embodiment of the invention are illustrated above.
[0124] Collectively, the components of the automated disclosure
processing application engine 2414 can process an insurance disclosure
and coordinate the transfer of information and an assessment between
entities. Users 2412a-n can focus more on deciding whether a particular
claim from a medical claimant is a valid claim.
[0125] Example methods that can be performed by an automated disclosure
processing application engine, in accordance with embodiments of
the invention, are illustrated in FIG. 1. The methods shown in FIG.
1 can be implemented in conjunction with the example system 2400
shown in FIG. 24. This method and other methods can be performed
or otherwise implemented on other system embodiments in accordance
with other embodiments of the invention.
[0126] While the above description contains many specifics, these
specifics should not be construed as limitations on the scope of
the invention, but merely as exemplifications of the disclosed embodiments.
Those skilled in the art will envision any other possible variations
that are within the scope of the invention. |