U.S. patent application number 11/426529 was filed with the patent office on 2007-01-11 for systems and methods for determining indications of fraud in healthcare claims.
Invention is credited to George J. Bregante, Daniel T. Day, Dennis J. Day, Edward R. Day.
Application Number | 20070011032 11/426529 |
Document ID | / |
Family ID | 37595957 |
Filed Date | 2007-01-11 |
United States Patent
Application |
20070011032 |
Kind Code |
A1 |
Bregante; George J. ; et
al. |
January 11, 2007 |
SYSTEMS AND METHODS FOR DETERMINING INDICATIONS OF FRAUD IN
HEALTHCARE CLAIMS
Abstract
A method of controlling healthcare claim payment losses
including accessing information about a claim after a payer is
prepared to pay, but prior to payment, applying at least one rule
to the information, wherein the at least one rule is adapted to
determine indications of fraud and if fraud is indicated, flagging
the claim, else recommending payment, wherein flagging of the claim
or recommending payment occurs prior to payment. Also, a healthcare
claim loss control system including a database having data related
to healthcare claims and a loss control engine in communication
with the database wherein the loss control engine accesses data
corresponding to a healthcare claim when the claim is ready for
payment, but before payment of the claim occurs and wherein the
claim scoring engine applies at least one rule adapted to identify
fraud and flags the claim for any indicated fraud before payment of
the claim.
Inventors: |
Bregante; George J.;
(US) ; Day; Dennis J.; (Corona del Mar, CA)
; Day; Daniel T.; (Corona del Mar, CA) ; Day;
Edward R.; (Newport Beach, CA) |
Correspondence
Address: |
KNOBBE MARTENS OLSON & BEAR LLP
2040 MAIN STREET
FOURTEENTH FLOOR
IRVINE
CA
92614
US
|
Family ID: |
37595957 |
Appl. No.: |
11/426529 |
Filed: |
June 26, 2006 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
60694182 |
Jun 27, 2005 |
|
|
|
Current U.S.
Class: |
705/4 ; 705/2;
706/47; 707/999.001 |
Current CPC
Class: |
G06Q 30/0225 20130101;
G06Q 10/10 20130101; G06Q 30/0185 20130101; G06Q 40/08 20130101;
G06Q 20/4016 20130101 |
Class at
Publication: |
705/004 ;
705/002; 706/047; 707/001 |
International
Class: |
G06Q 40/00 20060101
G06Q040/00; G06N 5/02 20060101 G06N005/02; G06Q 10/00 20060101
G06Q010/00; G06F 17/30 20060101 G06F017/30 |
Claims
1. A method of controlling healthcare claim payment losses, the
method comprising: accessing information about a healthcare claim
after a payer is prepared to pay the claim, but prior to payment of
the claim; applying at least one rule to the claim information,
wherein the at least one rule is adapted to determine indications
of fraud; and if indications of fraud are determined, flagging the
claim for fraud indications; else, recommending payment of the
claim, wherein flagging of the claim or recommending payment of the
claim occurs prior to the payer paying the claim.
2. The method of claim 1, wherein the payer provides the access to
the information about the healthcare claim.
3. The method of claim 1, wherein the claim is routed for further
investigation when indications of fraud are determined.
4. The method of claim 3, further comprising at least one of
recommending payment of the claim and providing results of the
further investigation to the payer prior to the payer paying the
claim.
5. The method of claim 1, wherein the method is performed by a
third party.
6. The method of claim 1, wherein the at least one rule comprises:
adding a number of units billed for a first code by a provider on
the claim to a number of units billed for the first code by the
provider on previous claims to determine a sum of the units billed
for the first code by the provider within an interval; comparing
the sum to a threshold; and flagging the claim for fraud
indications when the sum exceeds the threshold.
7. The method of claim 1, wherein the at least one rule comprises:
determining a total sum of units billed by a provider for a same
date of service, same provider identifier, same claim type, and
same or different claim number, compare the sum of units to a
threshold for the service; and flagging the claim for fraud
indications when the sum exceeds the threshold.
8. The method of claim 7, further comprising determining the
threshold for the service as a function of at least one of a
corresponding patient's weight and body mass index.
9. The method of claim 1, wherein the at least one rule comprises:
determining a distance between a service location and a patient's
home; comparing the distance to a threshold; and flagging the claim
for fraud indications when the sum exceeds the threshold.
10. The method of claim 1, wherein the at least one rule comprises:
identifying a date span from date in through date out for an
in-patient stay; evaluating any billed accommodation units; and
flagging the claim if a total of the billed accommodation units
exceeds the date span or if multiple units are billed for the same
date of service or if accommodation units are billed outside the
date span.
11. The method of claim 1, wherein the at least one rule comprises:
determining an age of a patient; determining a normal incidence age
range for a service; and flagging the claim when the patient's age
falls outside of the incidence range.
12. The method of claim 1, wherein the at least one rule comprises:
identifying the claim as corresponding to services which generally
indicate only a single visit and flagging the claim if more than
one of the services are billed within a threshold interval by the
same provider identifier, same claim type, and same or different
claim number.
13. A healthcare claim loss control system, the system comprising:
a database having data related to healthcare claims; and a
healthcare claim loss control engine in communication with the
database wherein the claim loss control engine accesses data
corresponding to a healthcare claim when the claim is ready for
payment, but before payment of the claim occurs and wherein the
claim scoring engine applies at least one rule adapted to identify
fraud and flags the claim for any indicated fraud before payment of
the claim.
14. The system of claim 13, wherein the loss control engine further
investigates claims having fraud indications and reports the
results of the fraud investigations.
15. The system of claim 14, wherein the loss control engine
provides additional loss control operations and wherein the
additional loss control operations are adapted to be applied to
claims satisfying the fraud rules.
16. The system of claim 13, wherein the loss control engine applies
at least one rule from the group consisting of total units billed
per interval, total units billed per service, excessive distance,
accommodations vs. length of stay, service age appropriateness, and
service frequency.
17. The system of claim 13, wherein the database comprises data at
least partially provided by a third party fraud identification
service.
18. A healthcare claim loss control system, the system comprising:
means for accessing information about a healthcare claim after a
payer is prepared to pay the claim, but prior to payment of the
claim; means for applying at least one rule to the claim
information, wherein the at least one rule is adapted to determine
indications of fraud; and means for flagging the claim for fraud
indications, if indications of fraud are determined, else for
recommending payment of the claim, wherein flagging of the claim or
recommending payment of the claim occurs prior to the payer paying
the claim.
19. The system of claim 18, wherein the means for accessing
information and the means for applying the at least one rule
comprises a database having data related to the healthcare claim
wherein at least a portion of the data is provided by the payer and
a healthcare claim loss control engine in communication with the
database.
20. The system of claim 18, wherein the means for flagging the
claim and recommending payment of the claim based on the at least
one fraud rule comprises a processor operating a claim loss control
engine under defined fraud rules and wherein the processor is
further in communication with the payer.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims the benefit of U.S. Provisional
Application 60/694182 filed Jun. 27, 2005 entitled "SYSTEMS AND
METHODS OF PROCESSING AND STORING HEALTHCARE DATA" which is
incorporated herein in its entirety by reference.
BACKGROUND OF THE INVENTION
[0002] 1. Field of the Invention
[0003] The invention relates to the field of healthcare claims and
to systems and methods to improve loss control in payment of
claims.
[0004] 2. Description of the Related Art
[0005] When an insured patient receives medical services and/or
products from a health care provider, a health care claim typically
results for reimbursement/payment of charges associated with the
health care services. A health care claim frequently undergoes some
type of internal processing by a payer, such as a health care
insurance company. Once the processing is completed, the claim is
forwarded for payment. Governmental regulations applying to the
health care insurance industry generally require that claims be
processed and paid as indicated in a timely manner.
[0006] A troublesome aspect of the health care field is that a
disproportionately large fraction of the costs incurred are
attributable to a disproportionately small fraction of the insured
population. This phenomena is at least partly to be expected as a
majority of people are relatively healthy and injury-free for a
large fraction of their life and thus would not be expected to
incur significant medical costs. However, there are non-negligible
unwarranted costs associated with at least some health care claims.
For example, honest mistakes and misunderstanding of proper
formulation of a health care claim can result in unwarranted,
inflated costs associated with the claim. In addition, incidents
arise of intentional abuse and/or fraud of the health care
provision and payment system. For example, a provider can duplicate
bill for the same service provided, over bill for the number of
units provided, and/or conduct excessive testing beyond that which
would be considered medically necessary for the given case.
SUMMARY OF THE INVENTION
[0007] Considering the substantial sums involved, it will be
appreciated that there is a need for loss control in health care
claim payments to mitigate losses for unwarranted payments made. As
used herein, loss control encompasses broad concepts entailing
multiple aspects of cost containment depending upon the particular
circumstances of a given claim. For example, loss control can
entail inhibiting payment on fraudulent claims. Loss control can
also entail verification that the actual services provided
correspond with claim payments requested and can further entail
revision of the claim should there be errors in correspondence
between the services provided and a corresponding claim payment.
Loss control can also, in certain implementations, include
identifying available payment discounts that may be available for
the services provided for the claim. In yet other implementations,
loss control can entail data analysis and resulting analytics to
identify emerging high risk/high cost situations, for example an
emerging new fraud scheme or a patient/patient population
exhibiting likely onset of future high cost claims.
[0008] However, certain limitations and difficulties have been
identified in more effectively providing loss control for payment
of health care claims. For example, recovering losses after payment
of a claim has occurred limits effectiveness for the payer to
recover these losses. In another aspect, while a variety of loss
control services exist, for example fraud identification services
and claim management services, a system for effectively
coordinating these services has been lacking. A further limitation
is that the proper coding of a health care claim for services
provided and possible fraud schemes can be relatively complex.
Thus, internal processing conducted for example by a payer, has
limited ability to identify for example coding errors and
fraudulent claims. In addition, in certain implementations the
pressures of handling a large number of claims each in a timely
manner can be such that the return on investment for a payer to
enact more thorough loss control processes is insufficient. An
additional limitations is that different clients often have
different formatting of information and this further complicates
efficient coordination of resources in controlling losses.
[0009] Various embodiments of the invention address the
above-identified needs and limitations in existing loss control
systems. Embodiments of the invention provide systems and methods
to more effectively perform loss control in payment of a health
care claim to provide cost saving benefits to the payer as well as
to safeguard or improve the integrity of a health care claim
system. At least certain embodiments of the invention provide loss
control intervention at a point in the processing of a health care
claim prior to payment of the claim. These embodiments provide the
significant advantage of providing at least some loss control
procedures before the claim is paid thereby reducing the value of
claim loses which otherwise need to be recovered after payment of
the claim.
[0010] At least certain other embodiments provide an efficient
single point of contact between payers, providers, and other
entities to more efficiently integrate information access and
sharing. These aspects facilitate more efficient and timely
processing of a health care claim to provide a payer with more
effective loss control, provide payment to the provider in a
timelier manner, and more effectively maintain integrity of an
overall health care and health care payment system.
[0011] In certain aspects, embodiments of the invention provide
claim optimization. As used herein, the terms "optimal",
"optimize," "optimizing," "optimization", "minimize", "maximize"
and the like are to be understood as commonly used terms of the art
referring simply to a process of evaluating and processing of a
claim to provide a more accurate claim. Claim "optimization" refers
generally to a process of identifying and correcting errors in a
claim, filtering for fraudulent claims, and or obtaining available
discounts for the claim. It will be understood that there are
frequently costs associated with improving the accuracy of a claim
and seeking discounts. Thus, in certain applications, optimization
of a claim involves a cost/benefit decision. In many applications,
available processing and information as well as time constraints
can result in processed claims that are more accurate and reflect
cost savings, but wherein the possibility of further improvements
in accuracy and/or additional cost savings may be available, at
least in certain instances. Thus, use of the terms "optimal",
"optimize," "optimizing," "optimization" and the like does not
imply that the described process results in a perfect result or
that any further improvements are not available. Thus, the terms
"optimize," "optimizing," and/or "optimization" are to be
interpreted as relative terms indicating generally improved quality
in an individual application and are not to be interpreted as
absolutes.
[0012] One embodiment includes a method of controlling healthcare
claim payment losses, the method comprising accessing information
about a healthcare claim after a payer is prepared to pay the
claim, but prior to payment of the claim, evaluating the claim
information and developing a score indicative of loss control
opportunities for the claim, and if the score exceeds a threshold,
flagging the claim to the payer for loss control opportunities,
else, recommending payment of the claim, wherein flagging of the
claim or recommending payment of the claim occurs prior to the
payer paying the claim.
[0013] Another embodiment includes a healthcare claim loss control
system, the system comprising a database having data related to
healthcare claims and a healthcare claim scoring engine in
communication with the database wherein the claim scoring engine
accesses data corresponding to a healthcare claim when the claim is
ready for payment, but before payment of the claim occurs and
wherein the claim scoring engine evaluates the claim for loss
control opportunities and generates at least one score for the
claim corresponding to the evaluated loss control opportunities
before payment of the claim.
[0014] A further embodiment includes a healthcare claim loss
control system, the system comprising means for accessing
information about a healthcare claim after a payer is prepared to
pay the claim, but prior to payment of the claim, means for
evaluating the claim information and developing a score indicative
of loss control opportunities for the claim, and means for flagging
the claim to the payer for loss control opportunities if the score
exceeds a threshold, else recommending payment of the claim,
wherein flagging of the claim or recommending payment of the claim
occurs prior to the payer paying the claim. These and other objects
and advantages of the invention will become more apparent from the
following description taken in conjunction with the accompanying
drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
[0015] FIG. 1 is a work-flow diagram of one embodiment of a
healthcare claims loss control system and method;
[0016] FIG. 2 is a block diagram illustrating one embodiment of a
healthcare claims loss control system and method and interfaces
with various parties;
[0017] FIG. 3 is a schematic illustration of one embodiment of
multiple loss control aspects of a healthcare claims loss control
system and method;
[0018] FIG. 4 is a more detailed block diagram of one embodiment of
a healthcare claims loss control system and method;
[0019] FIG. 5 is a block diagram of one embodiment of a healthcare
claims loss control scoring engine and possible further
processing;
[0020] FIG. 6 is a flow chart of one embodiment of a healthcare
claims loss control scoring system and method;
[0021] FIG. 7 is a block diagram of one embodiment of a healthcare
claims routing system and method for improved loss control;
[0022] FIG. 8 is a flow chart of one embodiment of a healthcare
claims routing system and method for improved loss control; and
[0023] FIG. 9 is a block diagram of one embodiment of fraud rules
that can be applied in of a healthcare claims loss control system
and method.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
[0024] FIG. 1 illustrates a high level work flow diagram for one
embodiment of a health care claims loss control system and method
100 including one embodiment of interaction of the system 100 with
a health care claim payment process. In this embodiment, in a block
10 a health care claim 5 is screened for eligibility. For example,
in one implementation, the claim 5 is screened to verify that the
claim corresponds to a qualified member of the payer's group and
that the premium is current for that member.
[0025] A block 20 follows wherein the compensability of the claim 5
is determined. For example, the block 20 can include confirming
that the services associated with the claim 5 are covered services
and that any indicated deductibles have been satisfied. In a block
30, the claim 5 is further processed to result in a medical bill
that would otherwise be ready for payment of the claim 5 in a block
40.
[0026] The actions and processes of blocks 10, 20, and 30 can also
be referred to as an adjudication process 50. The adjudication
process or block 50 refers, in one embodiment, to processing or
screening performed internally by a payer and resulting in a
medical bill that is otherwise ready for payment. It will be
understood that in certain embodiments, an adjudication process or
block 50 can include certain aspects of loss control. For example,
the screening of block 10 verifies that the claim 5 is associated
with an eligible member of the payer organization. The
compensability determination of block 20 inhibits payment of a
claim for services and/or products not covered by the payer.
[0027] In at least certain embodiments, a claim 5 which may have
undergone an adjudication process 50 is forwarded to the system 100
for additional loss control processing before being paid in a block
40. In one embodiment, the system 100 provides a validated and/or
normalized claim 5' wherein in at least certain instances, the
validated/normalized claim 5' represents costs savings compared to
the corresponding claim 5 before processing by the system 100. A
significant advantage of at least certain embodiments is that the
loss control processing provided by the system and method 100
occurs before payment of the claim in a block 40. Thus, any cost
savings associated with the claim 5' are realized before the claim
is paid reducing the need to recover comparable cost savings after
payment has already been made.
[0028] FIG. 2 is a block diagram illustrating one embodiment of a
health care claims loss control system and method 100 and
interfaces with one or more other entities or parties 60. In one
exemplary implementation, the other parties or entitles include one
or more of payer clients 60a, preferred provider organizations
(PPOs) and licensed providers 60b, patients, employers,
governmental agencies, etc. 60c, claims management services 60d and
fraud ID collection agencies 60e. In certain embodiments, the
system 100 is in communication with one or more of the other
parties or entities 60. In certain preferred embodiments,
connection/communication between the system 100 and any other
entities 60 is provided as a secure communication.
[0029] Implementation of various secure communication protocols,
password protection systems, encryption systems, digital signature
certificates, etc. will be well understood and readily implemented
by one of ordinary skill. As the system 100 provides a common link
among one or a plurality of other entities 60, the system 100 is
positioned to facilitate coordination and integration of the
abilities and needs of the various other entities 60 as well as to
facilitate more efficient exchange and utilization of information
therebetween. Thus, the system 100 can be considered to provide a
single point of contact for multiple parties 60.
[0030] FIG. 3 is a schematic illustration of multiple loss control
aspects provided by embodiments of the system and method 100 in
evaluating or processing a claim 5. One loss control aspect 101 of
the system and method 100 is adapted for loss control generally
directed to fraud and abuse which can also be considered to relate
to provider integrity. This loss control aspect 101 reviews health
care claims 5 that may represent questionable and/or abusive
billing practices.
[0031] In certain implementations, this loss control aspect 101
accesses databases that can be maintained by the system 100 itself
and, as an alternative, or in addition thereto, accesses databases
from other entities, such as fraud ID collection services 60e and
payers 60a. In one exemplary illustration of the loss control
aspect 101, screening can be done for providers lacking proper
licensing, former providers who are deceased, indicators that
identity theft of a provider may be present in the claim 5, a high
risk address of the provider, and/or providers with a previous
history of abusive billing. The loss control aspect 101 can also
utilize statistics, pattern recognition, and predictive models to
identify more complex fraud schemes as well as to detect new and
emerging fraud schemes. Further features of the loss control aspect
101 include the ability to screen for regulatory compliance issues,
such as identifying suspected or known foreign agents, terrorists,
drug traffickers and the like with whom transactions may be
prohibited.
[0032] Another loss control aspect 103 of the system 100 is also
directed generally to fraud and abuse and more particularly to code
editing compliance. A health care claim 5 will typically include
one or more service codes which indicate the particular service(s)
and/or product(s) provided as part of the claim 5. These health
care claim codes are based on national industry standards and
present numerous possibilities for mistake or fraudulent use. For
example, certain services which may be provided are assigned a
bundled or combination code where the associated service includes
multiple discreet services that are provided in combination.
[0033] Such services can be mistakenly or intentionally unbundled
and instead coded for the individual services rather than the
proper bundled service thereby improperly inflating the associated
cost of the claim 5. The loss control aspect 103 can also in
certain implementations, screen for "upcoding" where a code is
inappropriately used for a more complex or extensive service than
is properly indicated as well as duplicate or partial duplicate
coding.
[0034] The loss control aspect 103 can also code edit for
inappropriate assistant surgeon codes, codes which would generally
not be considered medical necessities for the associated treatment
or service, codes associated with excessive testing beyond that
needed, and misuse of code modifiers. The loss control aspect 103
is supported by independently sourced and documented code edit
references and thus satisfies regulated legal requirements.
[0035] A further loss control aspect 105 corresponds generally to a
repricing evaluation or optimization. In one exemplary
illustration, a claim 5 may already indicate a PPO discount
lowering the cost of the claim. The loss control aspect 105 can
further evaluate the claim 5 for possible eligibility for
additional PPO discounts, such as secondary or tertiary PPO
discounts. The system 100 maintains and accesses frequently updated
databases of available PPO networks and PPO providers under which a
claim 5 may be eligible for a discount. As another exemplary
illustration, a claim 5 may arise from services provided outside
the member's home network. The loss control aspect 105 can evaluate
or screen to determine that even though the claim 5 may not be
eligible for a primary PPO discount, there may exist alternative
PPO discounts available under a different network.
[0036] An additional loss control aspect 107 of the system 100 is
directed generally to provider discount negotiations or provider
repricing. In certain embodiments, the system 100 accesses data
sets, such as approved Medicare cost data, unit or service
benchmarks, provider facility cost structures and/or cost-to-charge
ratios for service facilities. The loss control aspect 107 can
include negotiation with the provider for the particular
facilities, equipment, and materials employed in the service
resulting in the claim 5 and can further use information gathered
by the system 100 to negotiate the associated costs.
[0037] In one embodiment, the loss control aspect 107 negotiates
the cost of the claim 5 from a cost-plus basis rather than a billed
charge-down approach. Thus, in certain implementations, the loss
control aspect 107 seeks to arrive at a mutually agreeable
negotiated repriced charge for the service based on a reasonable
and customary (R & C) charge over the net costs of the service
rather than negotiating what may be an inflated bill downwards. In
certain embodiments, any negotiated or repriced charges resulting
from the loss control aspect 107 include agreement on the part of
the provider that any difference between the repriced claim and the
originally billed claim will not be balance billed to the
member.
[0038] Yet another loss control aspect 109 of the system 100 is
directed generally to data analytics and decision support,
predictive modeling, and data warehousing. The loss control aspect
109 provides a large warehouse of data that can be employed to
predict future high risk members or member populations likely to
incur high cost services. The loss control aspect 109 can also
develop and provide predictive and analytic reports of service
demand and disease progress.
[0039] The loss control aspect 109 can also facilitate early
intervention to mitigate instances of high cost cases. For example,
the loss control aspect 109 might identify indications that an
individual member or member population exhibits indications likely
to result in future high cost claims. Early identification by the
aspect 109 can be helpful in mitigating such future costs, for
example by enacting earlier medical intervention.
[0040] FIG. 4 illustrates a block diagram of one embodiment of a
health care claims loss control system and method 100. In this
embodiment, a health care claim 5 results when the payer 60a
receives a bill from the provider 60b for services provided to the
member patient 60c. In certain embodiments, the claim 5 may undergo
an adjudication process or block 50 and in other embodiments the
claim 5 is provided to the system 100 without intervening
adjudication. In this embodiment, the system 100 includes at least
one processor 102 in communication with data storage 104 and memory
106.
[0041] It will be appreciated that in various embodiments, the
processor 102, the data storage 104, and/or the memory 106 can be
centrally located. In other embodiments, one or more of the
processor 102, the data storage 104, and/or the memory 106 are
distributed at multiple locations such that the system 100 can at
least in certain embodiments at least partially comprise a
distributed network. For example, in certain implementations it can
be preferable that the data storage 104 be at least partially
co-located with the processor 102 of the system 100. In other
embodiments, the data storage is at least partially embodied at a
location of another entity or party, such as a fraud ID collection
service 60e and/or payer 60a.
[0042] In one embodiment, the processor 102 communicating with the
data storage 104 and memory 106 operates a claim loss control
engine 110 and claims loss control rules 120. In various
embodiments, the claim loss control engine 110 and rules 120
evaluate or process and incoming claim 5 for improved loss control
before payment of the incoming claim 5. As previously noted,
components of the system 100 can be distributed such that, for
example a database associated with the data storage 104 can be
embodied in multiple locations, such as at least partly with the
payer 60a.
[0043] FIG. 5 illustrates in greater detail a block diagram of one
embodiment of a claim loss control engine 110 which in certain
embodiments comprises a claim scoring engine 110a. In various
embodiments, the claim scoring engine 110a evaluates the incoming
claim 5 for one or more characteristics or parameters and develops
an associated scored claim 5' wherein the scored claim 5' is
generally indicative of loss control or cost saving opportunities
for the claim 5. In one exemplary illustration, the claim scoring
engine 110a evaluates the claim 5 based on one or more of the loss
control aspects 101, 103, 105, 107, and/or 109. In one embodiment,
the claim loss control engine 110a also evaluates a claim for
possibility of an additional loss control aspect 111 relating to a
rapid payment discount. In this embodiment, the claim 5 may be
eligible for additional discounts in payment if agreement is
reached between the payer and provider for expedited payment of the
claim.
[0044] The scored claim 5' is indicative of loss control
opportunities for the particular claim. In one embodiment, this
includes one or both of a fraud score 130 and a discount score 132.
The fraud score 130 is indicative of deficiencies or fraudulent
aspects of the claim itself whereas the discount score 132 is
indicative of additional discounts which may be available for
payment of the claim 5 but not necessarily indicative of any
inherent problem in the claim.
[0045] In certain embodiments, clients utilizing the services
provided by the system and method 100 may simply desire further
information about the claim 5, such as a scored claim 5' indicating
loss control opportunities. Thus, in certain embodiments the system
and method 100 returns a recommendation 140 to the payer 60a such
that the payer 60a can take appropriate action in payment of the
claim 5'. In certain implementations, the recommendation 140 can
include a recommendation that the claim appears to be accurate and
that no additional loss control opportunities have been identified,
e.g., that the claim 5 should be paid as is. The recommendation 140
is in certain embodiments provided directly to the payer 60a and in
other embodiments, a database of the system 100 is updated such
that users of the system 100, such as the payer 60a can access the
recommendation 140 at their convenience.
[0046] In other embodiments, the scored claim 5' is a variable or
parameter for a score decision block 134. In the score decision
block 134, the system and method 100 determine appropriate further
processing or actions based at least partially on the result of the
scoring of the system and method 100. In one exemplary embodiment,
further processing of the scored claim 5' can include one or more
of a fraud investigations/provider integrity evaluation of block
136a, intelligent fraud analytics 136b, code edit compliance 136c,
coordination of benefits (COB) investigation 136d, repricing
negotiations 136e, data analytics 136f and/or rapid payment
discount 136g.
[0047] The selection of an appropriate one or more additional
process 136 for the particular scored claim 5' will depend on the
particular loss control opportunities represented in the scored
claim 5'. Additional processing 136 can, in various embodiments,
proceed in a serial or sequential manner or in a parallel manner or
mixture thereof In certain embodiments, particular additional
processing 136 can be subject to unique instructions from a given
payer client 60a. Implementation of particular selection and
application of additional processing 136 can be readily implemented
for the particular requirements of a given application by one of
ordinary skill.
[0048] In certain embodiments, the results of one or more
additional processes 136 performed further results in a
recommendation 140. In certain implementations, the recommendation
140 can further comprise revision to an actual claim payment amount
to be made in the claim payment block 40. For example, as
previously described a provider 60b may agree to repricing
negotiation that would be agreeable to the provider 60b as well as
to the member patient 60c such that the recommendation 140 includes
a lower payment amount such that the revised claim 5' resulting
from the recommendation 140 reflects cost savings already realized
for the payer 60a with satisfaction of payment to the provider 60b
and without balance billing to the member patient 60c.
[0049] FIG. 6 illustrates in flowchart form, similar embodiments of
the system and method 100 as illustrated in the block diagram of
FIG. 5. In one embodiment, a claim 5 is scored for fraud and/or
abuse in a block 202. The claim 5 is further scored for possible
discounts in a block 204 and the resulting scores are compared to a
threshold in block 206. A decision block 210 determines how a claim
5' is to be further processed.
[0050] As previously noted, in certain implementations the decision
of block 210 is that a scored claim 5' will simply be provided as a
recommendation 140 to the payer client 60a without further
processing. In other embodiments, the claim 5' will be further
processed according to one or more of blocks 210a, 210b, 210c,
210d, 210e, 210f, and/or 210g corresponding to the previously
described further processing of block 136a through 136g
respectively. The results of the further processing will be
incorporated in the recommendation 140 provided in block 212 and as
previously noted can in certain embodiments include an adjustment
in the recommended claim payment amount such that the payer 60a
realizes cost savings before payment of the claim.
[0051] FIG. 7 illustrates a block diagram of a further embodiment
of the system and method 100 comprising a claims loss control
engine 110 configured generally as a claims routing engine 110b. In
one embodiment, a claim 5 is provided to the system 100 generally
as previously described. However, rather than developing a score
for the claim 5, the claims routing engine 110b is capable of
automatically processing the claim 5 according to one or more
processing blocks 150.
[0052] In one embodiment, the claims routing engine 110b comprises
a fraud provider integrity and analytics block 150a which would
generate a fraud flag and report and in certain implementations be
further processed for fraud investigation. In one embodiment, the
claims routing engine 110b also comprises a fraud code edit block
150b configured for code editing compliance. One embodiment of the
claims routing engine 110b also comprises a coordination of
benefits (COB) investigations block 150c, a repricing negotiation
block 150d, a data analytics block 150e and a rapid payment
negotiation block 150f.
[0053] While FIG. 7 illustrates the blocks 150a through 150f of the
claims routing engine 110b arranged serially and in an illustrated
order, it should be understood that this is simply illustrative of
one exemplary embodiment. In certain embodiments, multiple blocks
150a through 150f can be performed serially and in a desired order.
In other embodiments, multiples of the blocks 150a through 150f can
be performed in parallel or in a combination of parallel and serial
processing.
[0054] FIG. 7 does however illustrate generally one embodiment of
arrangement of the blocks 150a through 150f of a claims routing
engine 110b that may be preferable in certain implementations. For
example, if a block 150a directed to fraud provider integrity and
analytics determines indications of a fraudulent claim, it may be
preferred that system and method 100 resources not be further
committed, for example to repricing negotiations 150d or rapid
payment negotiations 150f for a claim which may be fraudulent.
Instead, in certain implementations, it would be more preferred
that fraud issues raised in a block 150a be resolved before further
loss control analysis or that the recommendation 140 simply be that
the claim be refused for payment because of the fraud issues
revealed in block 150a.
[0055] FIG. 8 is a flowchart illustration of certain embodiments
corresponding generally to those illustrated and described with
respect to the block diagram of FIG. 7. In an exemplary embodiment,
a claim 5 proceeds through one or more of a provider and analytics
block 302, a code edits/analytics block 304, and investigation of
coordination of benefits block 306, a repricing negotiation block
310, a data analytics block 312, and/or a rapid payment negotiation
block 314. Again, as previously noted depending on the requirements
and indications of a given claim, one or more of the blocks 302,
304, 306, 3 10, 312, and/or 314 may be omitted or bypassed and
these blocks may be performed serially, in parallel, or in a
combination of serial and parallel processing. Also, a block 316 is
included wherein the recommendation 140 is provided to the payer
client 60a.
[0056] FIG. 9 illustrates various embodiments of fraud rules
embodied in certain embodiments of the further processing blocks
136a and/or 150a. FIG. 9 illustrates schematically various fraud
rules 160 that can be applied to a given claim 5 to screen the
claim 5 for possible indications of a fraudulent claim. In various
embodiments, this can include application of one or more fraud
rules 160a through 160f as well as additional rules. Fraud rule
160a is directed generally to a rule for evaluation of the total
units billed in a given interval.
[0057] The fraud rule 160a would generally be applied when units,
such as medication units, are billed to a claim and where
additional billing of similar units has previously occurred. In one
embodiment of the fraud rule 160a, a number of current units billed
in the claim 5 is added to a number of similar units previously
billed in associated claims by the provider within a given
interval, for example within a previous six month interval.
[0058] This results in a total sum of the units billed within the
selected interval including the units billed in the current claim
5. This sum is then compared to a threshold and the claim is
flagged for fraud indications if the sum exceeds the threshold for
total number of units within the given interval.
[0059] One embodiment of a fraud rule 160b is generally directed to
analyzing the total number of units billed for a single service. In
one embodiment, the total number of units billed in the claim for a
given service is totaled and compared to a determined threshold. In
one embodiment of the fraud rule 160b, the threshold for comparison
is determined as a function of at least one of the member patient's
weight and their body mass index. For example, it would be expected
that an appropriate total number of units billed for certain
services, for example medication or chemotherapy treatments, would
vary somewhat depending on the treated person's weight or size.
[0060] In one embodiment, a fraud rule 160c is directed generally
to evaluating distances between a member patient's home address and
a service location. For example, it would be expected that a member
patient would seek and receive service from a provider relatively
close to their home location. While in certain instances, a member
patient may simply be traveling and seek and receive service from a
provider, often an exaggerated distance from their home, an
excessive distance is an indicator of possible fraud.
[0061] Thus, in one embodiment, the fraud rule 160c calculates a
distance between the member patient's home address and a service
location and compares this distance to a threshold. In certain
embodiments, the distance threshold can vary depending on whether
or not one or more of the member patient's home address and/or
service location is a rural location versus an urban location.
Generally, it would be expected that patients and service providers
in an urban area would be expected to travel a lesser distance than
a member patient and service provider in a more rural setting.
[0062] One embodiment of a fraud rule 160d is directed generally to
evaluating billing of a combination unit to the patient's length of
stay. For example, it would be generally expected that there be a
one to one correspondence between the length of stay of a patient
at a service facility and the accommodation unit billed for that
stay. Thus, in one embodiment the fraud rule 160d identifies a span
from a date in, through a date out, for an inpatient stay.
[0063] The fraud rule 160d further evaluates any billed
accommodation units associated with the claim 5. The fraud rule
160d in one embodiment, flags the claim 5 for fraud indications if
a total of the billed combination units exceeds the date span of
the length of stay, or if multiple accommodation units are billed
for one or more same dates of service or if a combination units are
billed for dates outside the length of stay span.
[0064] One embodiment of a fraud rule 1 60e is directed generally
to evaluating the age appropriateness of services reflected in a
claim 5. For example, infants and young children generally have not
developed frontal sinuses. Thus, a claim coded for frontal sinus
procedures when the member patient is an infant or young child
would be unusual at best and an indicator of possible fraud.
[0065] Similarly, certain procedures and services would be expected
for a newborn baby but would be highly suspicious if indicated as
being provided to an adult or senior. Thus, in one embodiment, the
fraud rule 160e determines or accesses a normal age incidence range
for a given service. The fraud rule 160e compares a determined age
of the member patient to this normal age incidence range, and flags
the claim 5 for fraud indications if the member patient's age lies
outside of the normal age incidence range.
[0066] One embodiment of a service frequency rule 160f is directed
generally to evaluating a frequency history for a given service.
For example, certain services typically indicate only a single
visit and repeated visits indicating the same service type or
multiple services of the same type on a given date of service would
be highly suspicious and result in flagging the claim 5 for fraud
indications.
[0067] Although the above disclosed embodiments have shown,
described and pointed out novel features of the invention as
applied to the above-disclosed embodiments, it should be understood
that various omissions, substitutions, and changes in the form of
the detail of the devices, systems and/or methods illustrated may
be made by those skilled in the art without departing from the
scope of the present teachings. Consequently, the scope of the
invention should not be limited to the foregoing description but
should be defined by the appended claims.
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