U.S. patent application number 14/012430 was filed with the patent office on 2013-12-26 for medical payment system.
This patent application is currently assigned to First Access, Inc.. The applicant listed for this patent is First Access, Inc.. Invention is credited to Dorothy M. Baylor, Kimberly A. Darling.
Application Number | 20130346100 14/012430 |
Document ID | / |
Family ID | 39182305 |
Filed Date | 2013-12-26 |
United States Patent
Application |
20130346100 |
Kind Code |
A1 |
Darling; Kimberly A. ; et
al. |
December 26, 2013 |
MEDICAL PAYMENT SYSTEM
Abstract
A medical payment system is described in which a provider of
medical goods and/or services submits, via telephone or other
communications medium, a request for payment amount determination
for a patient encounter. A price determination system determines
which of a plurality of fee schedules negotiated by the provider
applies to the patient encounter and calculates, based at least in
part on information entered by the provider, a payment amount for
the encounter. In one embodiment, the provider receives the payment
amount information while the patient is at the point of service. In
one embodiment, the provider may use the system to submit a claim
for payment by at least one responsible party.
Inventors: |
Darling; Kimberly A.;
(Trabuco Canyon, CA) ; Baylor; Dorothy M.; (Rancho
Santa Margarita, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
First Access, Inc. |
Mission Viejo |
CA |
US |
|
|
Assignee: |
First Access, Inc.
Mission Viejo
CA
|
Family ID: |
39182305 |
Appl. No.: |
14/012430 |
Filed: |
August 28, 2013 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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13486759 |
Jun 1, 2012 |
8527298 |
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14012430 |
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13209259 |
Aug 12, 2011 |
8195482 |
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13486759 |
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|
12027196 |
Feb 6, 2008 |
8019627 |
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13209259 |
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10338965 |
Jan 8, 2003 |
7346522 |
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12027196 |
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60346705 |
Jan 8, 2002 |
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Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G16H 10/65 20180101;
G06Q 40/08 20130101; G06Q 10/10 20130101; G06Q 20/102 20130101;
G06Q 20/14 20130101; G06Q 40/02 20130101 |
Class at
Publication: |
705/2 |
International
Class: |
G06F 19/00 20060101
G06F019/00 |
Claims
1. A computer system of facilitating payment of health care
benefits comprising: multiple fee schedules; healthcare provider
identification information; and computer hardware configured to:
identify a payer that has agreed to pay a healthcare provider on
behalf of a patient subject to conditions; select at least one fee
schedule from the multiple fee schedules based at least in part on
the healthcare provider identification information; and calculate a
payment amount based at least in part on the selected fee schedule;
verify that the payment amount is a bona fide medical expense;
approve the payment amount only when the payment amount has been
verified; and send the verification of the payment amount to an
account associated with the patient; and transmit a copy of the
payment amount to the healthcare provider.
2. The system of claim 1 wherein the account is a bank account.
3. The system of claim 2 wherein the bank account is associated
with a card that is at least one of the group consisting of: a
stored value card, a medical credit card, and a medical plan
card.
4. The system of claim 1 wherein the computer hardware is further
configured to approve multiple payment amounts.
5. The system of claim 1 wherein the computer hardware is further
configured to receive and store multiple payment amounts.
6. The system of claim 1 wherein the computer hardware is further
configured to process and store multiple payment amounts associated
with multiple patient encounters.
7. The system of claim 1 further comprising an interactive voice
response system configured to prompt the healthcare provider to
enter information about a patient encounter.
8. The system of claim 1 further comprising an interactive voice
response system configured to communicate information about the
approval of the payment amount.
9. The system of claim 1 further comprising an interactive voice
response system configured to communicate information about the
account.
10. The system of claim 1 wherein the computer hardware is further
configured to determine a portion of the payment amount to be paid
by the patient and a portion of the payment amount to be paid from
a source of medical funds.
11. The system of claim 10, wherein the source of medical funds is
a third-party payor.
12. The system of claim 10, wherein the source of medical funds is
a flexible savings account.
Description
PRIORITY CLAIM
[0001] This application is a continuation of U.S. patent
application Ser. No. 13/486,759, filed Jun. 1, 2012, entitled
MEDICAL PAYMENT SYSTEM, which is a continuation of U.S. patent
application Ser. No. 13/209,259, filed Aug. 12, 2011, entitled
MEDICAL PAYMENT SYSTEM, which is a continuation of U.S. patent
application Ser. No. 12/027,196, filed on Feb. 6, 2008, entitled
MEDICAL PAYMENT SYSTEM, which is a continuation of U.S. patent
application Ser. No. 10/338,965, filed on Jan. 8, 2003, entitled
MEDICAL PAYMENT SYSTEM, and claims the benefit of priority under 35
U.S.C. .sctn.119(e) of U.S. Provisional Application No. 60/346,705,
filed on Jan. 8, 2002, entitled HEALTH CLAIM SUBMISSION SYSTEM,
each of which is hereby incorporated herein by reference in its
entirety.
BACKGROUND OF THE INVENTION
[0002] 1. Field of the Invention
[0003] The present invention is related to payment systems, and, in
particular, to medical payment systems.
[0004] 2. Description of the Related Art
[0005] Payment amounts for medical care in the US are increasingly
set by Preferred Provider Organizations (PPO's) that negotiate
reduced rates with medical providers for medical services and goods
provided to patients. Agreeing to accept the reduced rates offered
by a PPO introduces a medical provider to the population of
patients that are affiliated with the PPO. Individual medical
providers may negotiate contracts with many different PPO's, each
with its own negotiated fee schedule that specifies the contracted
payment amount for each medical good and service offered by the
provider.
[0006] Fee schedules are updated when fees change, especially when
a negotiated fee is based on another rate, such as an agreed
percentage off of standard Medicare rates. Fee schedule updates are
typically transmitted to providers as printed pages of updates that
can be kept in the provider's office in binders that may be
numerous, unwieldy to handle, and difficult to reference.
Attempting to quickly determine which fee schedule is the
appropriate one to use for a given patient encounter can be
difficult for the provider, especially when the patient belongs to
a health plan with access to fee schedules from more than one
PPO.
[0007] Some PPO's maintain websites that providers can access via
computer network in order to get payment amount information based
on the PPO's current fee schedule, but providers have thus far
demonstrated reluctance to access payment information or to submit
claims for payment via computer. According to one report, only 10%
of providers who could use the computer to access payment amount
information do so. Several factors may help to explain this fact:
lack of available computer equipment at the time of patient
check-out, lack of comfort on the part of the provider in using the
computer and interacting with the various input requirements and
interface styles of the different PPO websites, inability of the
PPO website to provide a quick and easy interface to its services,
and lack of speed and/or capacity of the provider's computer
connection, amongst other reasons. Furthermore, having access, by
paper or by computer, to individual PPO fee schedules does not help
the provider determine which PPO fee schedule is appropriate to use
for a given patient encounter when the patient's health plan offers
access to more than one PPO fee schedule.
SUMMARY OF THE INVENTION
[0008] A medical payment system is described that allows a medical
provider to communicate by telephone, using voice and/or telephone
keypad, to submit information about an encounter with a patient and
to receive information about an associated payment amount owed to
the provider for the medical services and goods provided. In some
embodiments, an interactive voice response system (IVRS) allows the
provider and the price determination system to communicate in a
manner that is convenient and easily understandable for the
provider.
[0009] A medical payment system is described that allows a medical
provider to request and to receive payment amount information for
an encounter with a patient who belongs to a health plan that
comprises one or more negotiated Preferred Provider Organization
(PPO) fee schedules. A price determination system locates an
appropriate fee schedule for the encounter and calculates a payment
amount for medical goods and/or services associated with the
patient encounter. For health plans that comprise a plurality of
fee schedules, the price determination system accesses information
about a hierarchical ranking of the fee schedules. The price
determination system selects, from amongst the fee schedules
negotiated by the provider, the fee schedule that has the highest
ranking in the hierarchy, and uses the selected fee schedule to
calculate the payment amount for the patient encounter.
[0010] In some embodiments, when payment of all or part of the
calculated payment amount is the responsibility of at least one
party or entity other than the patient, the provider may also use
the system to submit a claim to a responsible third party or
entity, such as a medical insurance company or third party
administrator, a medical credit card account, or other source of
funds dedicated for payment of the patient's medical expenses. In
one embodiment, information about the calculated payment amount can
be transmitted to a responsible third party or entity so that
payment may be transmitted directly to the provider's bank
account.
[0011] In one embodiment, a healthcare price determination method
is described, in which the method comprises: receiving, via
telephone, information about at least one patient encounter with a
medical provider; determining the contracted payment amount
associated with the encounter; and communicating via a voice
response system the determined payment amount to at least the
medical provider. The price determination method may further
comprise transmitting information about the payment amount to a
responsible party or entity, so that a claim for payment to the
provider may be submitted, and payment may be subsequently
transmitted to a bank account associated with the provider.
[0012] For purposes of summarizing embodiments of the invention,
certain aspects, advantages, and novel features of the invention
have been described herein. It is to be understood that not
necessarily all such aspects, advantages, or novel features will be
embodied in any particular embodiment of the invention.
BRIEF DESCRIPTION OF THE DRAWINGS
[0013] FIG. 1 depicts an overview of one embodiment of a medical
payment system that comprises a price determination system.
[0014] FIG. 2A depicts one embodiment of an eligibility list used
by a price determination system.
[0015] FIG. 2B depicts one embodiment of a priority list used by a
price determination system.
[0016] FIG. 2C depicts one embodiment of a provider list used by a
price determination system.
[0017] FIG. 3 is a flowchart that depicts one embodiment of a
medical payment system.
[0018] FIGS. 4A and 4B (hereinafter referred to collectively as
"FIG. 4") present a flowchart that depicts one embodiment of an
encounter information input system.
[0019] FIG. 5 is a flowchart that depicts one embodiment of a
method to determine a contracted payment amount for a patient
encounter.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0020] A medical payment system is described in which a provider of
medical goods and/or services submits, via telephone or other
communications medium, a request for payment amount determination
for a patient encounter and in which the provider receives via an
interactive voice response system (IVRS) information about the
requested payment amount. A price determination system determines
which of a plurality of fee schedules negotiated by the provider
applies to the patient encounter and calculates, based at least in
part on information entered by the provider, a payment amount for
the encounter, which it communicates to at least the provider. In
one embodiment, the provider receives the payment amount
information while the patient is at the point of service. In one
embodiment, the provider receives information about a first portion
of the payment amount, if any, for which it is the patient's
responsibility to pay and a second portion of the payment amount,
if any, which is to be paid by another responsible party or entity.
In one embodiment, the provider may use the system to submit a
claim for payment to at least one responsible party or entity.
[0021] FIG. 1 depicts an overview of one embodiment of the medical
payment system. In brief, FIG. 1 depicts a system in which a
patient 100 goes to a medical provider 110 for medical goods and/or
services. An instance in which the patient 100 visits the provider
110 and receives medical goods and/or services can be called a
patient encounter. The medical provider 110 communicates by
telephone or by other communications method with a price
determination system 115 in order to determine the payment amount
due to the provider 110 for the encounter. The price determination
system 115 calculates a payment amount, as will be described in
greater detail below and communicates the amount to the provider
110 and, if applicable, to one or more parties or entities that are
responsible for paying the provider 110. In one embodiment, the
price determination system 115 communicates the payment amount back
to the provider's office 110 immediately so that the patient 100
can pay the provider 110 before leaving the provider's office 110.
In one embodiment, when some or all of the payment amount is to be
paid by a third-party payor 190, such as a medical insurance
company, or from a medical credit card account 195, or is to be
paid from a purse 192, as will be described in greater detail
below, the price determination system 115 communicates information
about the payment amount to the payor 190, the purse 192 and/or the
medical credit card account 195 so that payment may be made
directly to a bank account 112 associated with the medical provider
110.
[0022] Describing FIG. 1 now in more detail, the provider 110
depicted may be a doctor, a pharmacist, a dentist, an optometrist,
a hospital, or other medical practitioner or provider of medical
goods or services. A representative of the provider 110, such as a
receptionist, billing specialist, or other assistant, may initiate
and execute the communication between the provider's office 110 and
the price determination system 115, and, for purposes of this
description, the term "provider" will refer to a provider or other
person operating on behalf of the provider in communicating with
the price determination system 115.
[0023] In one embodiment, the patient 100 presents to the provider
110 a medical plan card 105 that represents the patient's 100
membership in a group, known for purposes of this application as a
client group, that offers a medical plan to its members. In one
embodiment, access to the medical plan confers upon the patient 100
eligibility to receive medical care and/or goods at a contracted
reduced rate.
[0024] The client group may provide discounted rates on medical
goods and services for their members by building a medical plan
from medical pricing contracts available through one or more
Preferred Provider Organizations (PPO's). The PPO's negotiate
pricing contracts with medical providers who agree to accept
individually determined reduced payment rates for their goods and
services in exchange for access to the patient base offered by the
PPO. In one embodiment, the medical providers 110 also agree to
accept reduced payment rates in return for a guarantee of immediate
or expedited payment for patient encounters. A medical provider 110
typically contracts with a number of PPO's and may thus have agreed
to accept a wide variety of contracted payment rates for each given
medical good or service. For the provider 110 to determine the
correct contracted rate for the goods and services associated with
a given patient encounter is typically a complex and time-consuming
task and often cannot be accomplished while the patient 100 is
waiting to check out from the provider's office 110. Thus, the
provider 110 may lose the opportunity to receive payment at the
time of service and may have to expend time and money to bill the
patient 100 at a later date and to hope to receive payment without
enduring a protracted delay.
[0025] In one embodiment, information on the medical plan card 105
comprises a telephone number that allows the provider 110 to dial
and access via telephone an interactive voice response system
(IVRS) that is associated with the price determination system 115
and that is configured to accept and to transmit information about
a calculated payment amount for the patient encounter, as will be
described in greater detail with reference to FIGS. 3-5 below. In
one embodiment, the provider 110 communicates with the price
determination system 115 about a calculated payment amount for the
patient encounter using a computer that is configured to access a
computer network, such as the Internet, to which the price
determination system 115 is also connected. In other embodiments,
other methods of communication are used that allow the provider 110
to receive payment amount information for a patient encounter,
including by way of example, dedicated communication lines,
telephone networks, wireless data transmission systems, two-way
cable systems, customized computer networks, interactive kiosk
networks, automatic teller machine networks, interactive television
networks, and the like.
[0026] One advantage of a telephone-based embodiment is the ease of
use and uniformity of availability that it offers to the provider
110. While computers are becoming increasingly common in provider
offices, discrepancies still exist in the capabilities of computer
equipment and staff at provider offices. Lack of an available
computer at a provider's check-out desk, lack of reliable computer
network connection, slow transmission rates, and inability or
unwillingness of office staff to use the computer are all
conditions that currently exist. In fact, although computer systems
for submitting some types of medical insurance claims for later
payment do exist, statistics indicate that only around 10% of
provider offices currently choose to make use of such systems.
Telephones, on the other hand, are virtually ubiquitous in medical
provider offices, and office staff are familiar and comfortable
with their operation.
[0027] The ability on the part of the provider 110 to access
payment information, whether by telephone or by other communication
method, at the point and time of service represents an improvement
over current systems in which the provider 110 typically waits
three to six months for payment. In some current systems, the
provider 110 submits a paper-based request for payment information
to a PPO and must wait for a written response before being able to
accurately bill the patient 100. In some current systems, the
provider 110 bills the patient 100 a standard rate that may exceed
the contracted PPO rate to which the patient 100 is entitled and
that must later be adjusted and refunded. In such systems, even if
a patient 100 desires to pay at the point of service, accurate
payment amount information may not be readily available. In
embodiments where a patient 100 shares responsibility for paying
the provider 110 with another party or entity, such as a medical
insurance company 190 or a source of funds 192 for payment of the
patient's medical expenses, communicating with the price
determination system 115 at the point of service allows the
provider 110 to accurately inform the patient 100 of the portion of
the total payment amount for which the patient 100 is responsible
and to request immediate payment for that portion.
[0028] In one embodiment, communicating with the price
determination system 115 also allows the provider 110 to submit a
claim on behalf of the patient 100 to any parties or entities 190,
192, 195 that are responsible to pay the provider 110 for all or
part of the payment amount associated with the patient
encounter.
[0029] As depicted in the embodiment of FIG. 1, the price
determination system 115 comprises client-specific data 120, which,
when supplemented as needed by price calculation data 125, allows
the price determination system 115 to accurately calculate the
contracted payment amount for a patient encounter. In one
embodiment, the price determination system 115 operates using
computer program logic that may advantageously be implemented as
one or more computer modules configured to execute on one or more
processors. For the purposes of this description, computer modules
may comprise, but are not limited to, any of the following:
software or hardware components such as software object-oriented
software components, class components and task components,
processes methods, functions, attributes, procedures, subroutines,
segments of program code, drivers, firmware, microcode, circuitry,
data, databases, data structures, tables, arrays, or variables.
[0030] The client-specific data 120 of the price determination
system 115 comprises information specific to the medical plan of
the client group to which the patient 100 belongs and instructions
about how payment determination is to be carried out for encounters
associated with the client group. The price calculation data 125
comprises information that may apply to all or many of the client
groups serviced by the price determination system 115 and that may
be used for calculating a payment amount for an encounter involving
a patient from any of the client groups associated with the price
determination system 115. In one embodiment, client-specific data
120 is implemented as a computer module.
[0031] In one embodiment, client-specific data 120 for a given
client group is indexed or accessed via a client group access
number 130, and dialing the telephone number printed on the
patient's 100 medical plan card 105 automatically connects the
provider 110 to the appropriate client group access number 130 for
the client group to which the patient 100 belongs. Thus, the price
determination system 115 is able to provide payment information for
patients 100 from a variety of medical plans using a single,
simple, standardized interface and to quickly access the
appropriate information in order to calculate an accurate payment
amount for the patient encounter.
[0032] FIG. 1 depicts some examples of the types of client-specific
data 120 that may be stored and used by the price determination
system 115 in determining the contracted payment amount for an
encounter and in submitting a claim for the determined amount to
one or more responsible parties. In some embodiments, some or all
of the client-specific data 120 are. implemented as computer
modules, as was described above.
[0033] An eligibility list 135, which will be described in greater
detail with reference to FIG. 2A, comprises information about
whether a given patient 100 is eligible for some, all, or none of
the benefits offered to members of the client group. A provider
list 140, which will be described in greater detail with reference
to FIG. 2B, comprises information about providers who are
affiliated with the PPO's that have contracted with the client
group. A priority list 145, which will be described in greater
detail with reference to FIG. 2C, comprises information about a
hierarchy of PPO's that make up a medical plan and about how to
determine the correct contracted rate for a provider who is
affiliated with more than one PPO.
[0034] Fee schedules 150 stored with the client-specific data 120
of a given client group comprise information about how to calculate
the payment amount agreed to by a given provider 110 in affiliation
with a given PPO. In some embodiments, the fee schedules 150 are
implemented as one or more computer modules. In some embodiments,
the agreed amounts are fixed and are constant for all providers 110
affiliated with the PPO. In some embodiments, providers are grouped
by their zip codes, and providers in a given zip code are paid at
the same rate. In some embodiments, the payment amounts are
calculated as a percentage off the provider's 110 usual billed rate
for the service or good. In some embodiments, the amounts are
calculated using standard Medicare rates as a basis. In some
embodiments, rates for certain goods or services are calculated in
one way, while rates for other goods or services are calculated in
another way. In some embodiments, a PPO may have arrived at
different agreements with different affiliated providers for
various goods and services, and information describing these
agreements is stored within the fee schedule 150 for the PPO. Thus,
in some embodiments, the client-specific data 120 for a given
client group may comprise a fee schedule 150 for each PPO that
forms a part of the client group's medical plan.
[0035] Fee schedules are updated periodically, often every four to
six weeks, in order to reflect changes in a PPO's contracted rates.
Using the price determination system 115 to easily access current
and accurate payment amount information at the point of service
rather than attempting to locate the desired information in written
format using the numerous and often unwieldy binders provided by
individual PPO's is another advantage offered to the patient 100
and the provider 110 by the price determination system 115.
[0036] Client-specific data 120 for a client group also comprises
benefit coverage/payment rules 155 that provide instructions to the
price determination system 115 regarding how the patient encounter
payment amount is to be calculated for the client group's medical
plan and how claims to responsible parties and entities are to be
submitted for the client group's medical plan. In one embodiment,
the benefit coverage and payment rules 155 are implemented as one
or more computer modules. Benefit coverage/payment rules 155 will
be described in greater detail below, still with reference to this
figure.
[0037] As described above, in addition to the client-specific data
120 indexed by client group access number 130, the price
determination system 115 also comprises general purpose price
calculation data 125 that may be useful for determining a
contracted payment amount for a patient encounter associated with
any client group. Some examples of such price calculation data 125
are depicted in FIG. 1.
[0038] Accurately describing the procedures associated with a
patient encounter can be accomplished using Current Procedural
Terminology (CPT) codes 160 and CPT modifiers 165 that are defined
and maintained by the American Medical Association and that are
used as an industry standard to describe over seven thousand
different procedures. In one embodiment, each CPT code 160 is
associated with a multiplier value that is used in conjunction with
information from the fee schedule 150 to calculate the contracted
payment amount. For example, a fee schedule may indicate that for
providers in a given zip code area, all procedures with CPT codes
160 beginning with a "9," which indicates an office visit
procedure, are paid at a rate of $5.40 per multiplier unit. If an
extended office visit, with CPT code "90028," has a multiplier
value of 8.2, then a provider 110 in the given area who requests
pricing for an extended office visit will be given the
PPO-negotiated payment amount of $44.28. In one embodiment, the
price calculation data 125 also comprises Health Care Procedure
Codes (HCPC), which use a five-digit alphanumeric system to
identify coding categories not covered by CPT codes.
[0039] Other price calculation data 125 that may be stored by the
price determination system 115 are ICD-9 codes 170, which are an
industry standard used to describe medical diagnoses, current
Medicare rates 175, which may be used in some situations as the
basis for a PPO-negotiated payment amount, and tables of zip codes
180. Some, all, or none of these types of data, along with other
data used by the price determination system 115 to calculate a
contracted payment amount for a patient encounter and for
apportioning responsibility for paying the payment amount may be
stored as general purpose price calculation data 125. In some
embodiments, some or all of the price calculation data 125 is
implemented as one or more computer modules.
[0040] Using information from the client-specific data 120 and any
necessary price calculation data 125, the price determination
system 115 is able to calculate the appropriate contracted payment
amount for the patient encounter.
[0041] As was described briefly above, the client-specific data 120
comprises benefit coverage and payment rules 155 that instruct the
price determination system 115 on how to calculate the contracted
payment amount and, if desired, how to further process the payment
amount information for a given client group's medical plan. In some
embodiments, the benefit coverage and payment rules 155 allow the
price determination system to accommodate health plans in which
responsibility for paying some or all of the contracted payment
amount may be shared with the patient 100 by a third-party payor
190, a medical credit card account 195, or a medical payment fund
192. The benefit coverage and payment rules 155 are formulated to
suit the needs of the given medical plan and to allow the price
determination system 115 to flexibly serve the needs of a wide
variety of medical plans.
[0042] As an example, in one embodiment, a client group's medical
plan may provide access to PPO-negotiated rates for medical goods
and services that the patient 100 agrees to pay to the provider 110
in full at the point of service. In this example, the benefit
coverage and payment rules 155 may instruct the price determination
system 115 to use the client-specific data 120 and the price
calculation data 125 to calculate the contracted payment amount and
to communicate the amount back to the provider 110 verbally using
the IVRS. In some embodiments, options may also be provided to send
a written copy of the price determination to the provider 110 via
fax transmission and/or to the patient's home address via postal
service.
[0043] As another example, a client group's medical plan may
provide access to PPO-negotiated rates for medical goods and
services that the patient 100 agrees to pay to the provider 110 in
full at the point of service using a dedicated medical credit card
195. In one embodiment, a medical credit card 195 is different from
a regular credit card in that charges made to the medical credit
card 195 will only be approved if the credit card company receives,
prior to the request for approval, verification from the price
determination system 115 that the charge is for a bona fide medical
expense. In one such embodiment, the medical plan card 105 may also
be the medical credit card.
[0044] In one example of a medical credit card health plan, the
benefit coverage and payment rules 155 may instruct the price
determination system 115 to calculate the payment amount for the
encounter, to send payment amount information to the provider
office 110 so that the patient 100 can pay the provider 110 using
the medical plan/credit card 105 in the provider's office. The
price determination system 115 further sends verification of the
encounter and the payment amount to the medical credit card company
195 so that the medical credit card charge will be approved. In
such an embodiment, the price determination system 115 may send a
verification message to the medical credit card company 195 that
comprises patient 100 identification information, provider 110
identification information, and the calculated payment amount. When
the associated charge request is received by the medical credit
card company 195, if the patient identification 100, the provider
identification 110, and the payment amount match those received in
the verification message, the charge is approved, and payment is
sent to the provider's bank account 112.
[0045] In another example of a medical credit card health plan, in
one embodiment the benefit coverage and payment rules 155 may
instruct the price determination system 115 to calculate the
payment amount for the encounter and then to transmit a charge
request directly to the medical credit card company 195. Once
approval of the charge is received by the price determination
system 115 from the medical credit card company 195, the price
determination system 115 can transmit this information back to the
provider's office 110.
[0046] As another example, a client group's medical plan may
provide access to PPO-negotiated rates for medical goods and
services in conjunction with a "purse" 192, which, for purposes of
this description, is a fund of money that is available for payment
of a patient's approved medical expenses. In one embodiment, a
purse 192 may be funded by the patient 100 and/or by the patient's
employer. In one embodiment, funds for the purse are deducted on a
pre-tax basis from a patient's 100 paycheck and are available for
paying Internal Revenue Service (IRS)-approved medical expenses.
Some examples of purses 192 and the names by which they are known
are: flexible savings account (FSA), medical savings account,
health savings account, and personal care account. In one
embodiment, a medical plan card 105 used in conjunction with such a
medical plan may also serve as a "stored value card."
[0047] In conjunction with this type of health plan, in one
embodiment, the client-specific data 120 may further comprise a
list of approved medical goods and services, which may be
identified by CPT code. The eligibility list 135 may further
comprise information about an available balance of funds in the
patient's purse 192. The benefit coverage and payment rules 155 may
instruct the price determination system 115 to consult the list of
approved medical goods and services to verify that the encounter is
associated with approved goods and services or to calculate an
approved portion of the payment amount, if not all of the
encounter's goods and services are approved. The benefit coverage
and payment rules 155 may further instruct the price determination
system 115 to verify that sufficient funds exist in the purse 192
to cover the approved portion of the calculated payment amount,
and, in one embodiment, to submit a claim to the purse 192 so that
funds covering the approved portion of the payment amount are
deducted from the purse 192 and are deposited in the medical
provider's bank account 112. In one embodiment, the price
determination system 115 can then communicate with the provider's
office 110 via IVRS and/or fax transmission information about the
calculated payment amount and about any approved amount paid from
the patient's FSA, or other purse.
[0048] In addition to the immediate payment advantage thus afforded
to the provider 110, such a medical payment system also provides an
advantage to the patient 100 in that the patient 100 need not first
pay out of pocket for approved expenses and then later submit a
written request for reimbursement, but may have the funds deducted
from the purse 192 automatically.
[0049] In another example, the price determination system 115 may
calculate the contracted payment amount on behalf of a third party
payor 190 that may be responsible for paying some, all, or none of
the payment amount to the provider 110. A third party payor 190 may
be a medical insurance company, a self-insured employer that
provides its own insurance for its employees, a third-party
administrator for a self-insured employer, or another entity that
is responsible for paying some or all of a patient's medical
expenses and that has negotiated for discounted rates available
from a set of PPO's. Thus, in some embodiments, in order to
correctly determine and to apportion responsibility for paying the
calculated payment amount to the provider 110, the benefit
coverage/payment rules 155 may describe which medical goods and
services are covered by the payor 190, as well as benefit payment
levels for those that are covered.
[0050] For example, some medical plans cover well-baby check-ups,
while other medical plans do not. Some plans will pay for 80% of
the contracted payment amount for a basic procedure, but only 50%
of certain laboratory tests. Some services, such as chiropractic
treatments, may be covered for only up to ten visits a year or ten
visits per injury. Some plans have an annual maximum that they will
pay. Using the benefit coverage/payment rules 155, client-specific
information stored about the patient in the eligibility list 135,
and the calculated payment amount, the price determination system
115 is able to apportion responsibility for paying the provider 110
for the patient encounter.
[0051] The benefit coverage/payment rules 155 may instruct the
price determination system 115 to submit a claim for approved
expenses to the third-party payor 190. In some embodiments, such a
claim comprises information desired by the payor, such as, for
example, patient 110 and provider 110 identification, and CPT 160
and ICD-9 170 codes associated with the encounter, and calculated
payment amount. In some embodiments, the benefit coverage/payment
rules 155 will also instruct the price determination system 115 to
notify the provider 110 of the claim submission and of any payment
amount not included in the claim submission that remains for the
patient 100 to pay.
[0052] In other examples, client groups may provide a medical plan
that is a combination of the medical plans described above. For
example, a health plan may offer medical insurance coverage 190 in
conjunction with an FSA purse 192 that can be used to pay for
approved expenses that are not covered by the medical insurance
190. Or, a health plan may offer medical insurance coverage 190 in
conjunction with an FSA purse 192, as above, with the added feature
of a medical credit card 195 that can be used to pay for expenses
that are not covered by either the medical insurance 190 or the FSA
purse 192. The flexible nature of the price determination system
115 together with the expressive capabilities of the benefit
coverage and payment rules 155 allows the price determination
system 115 to serve a wide variety of client groups, each with
different memberships, providers, PPO affiliations, and health
plans, while providing a universally-available, easy-to-use
interface to the provider 110. In embodiments that access the price
determination system 115 via the telephone, accessing the correct
information for a given encounter may be achieved quickly and
easily by dialing the provided telephone number.
[0053] FIG. 1 depicts examples of three types of parties or
entities that may hold full or partial responsibility for payment
of a payment amount calculated by the price determination system
115. However, as will be familiar to one of ordinary skill in the
art, other types and examples of parties and entities desiring
information about the calculated payment amount and payment
responsibility apportionment determined by the price determination
system 115 may also be incorporated in the system and are also
envisioned in embodiments of the system described.
[0054] FIG. 1 depicts the client-specific data 120 and the price
calculation data 125 that is used by the price determination system
115 as being stored within the price determination system 115.
However, as will be familiar to one of ordinary skill in the art,
in other embodiments, some or all of the information may be stored
in one or more of the parties or entities 190, 192, 195 or in
another external data storage facility. Accessing some or all of
the client-specific data 120 and/or the price calculation data 125
externally may be accomplished using any of a variety of known
communications methods, such as, for example, dedicated high-speed
and/or high-volume communication lines, telephone networks,
wireless data transmission systems, two-way cable systems,
customized computer networks, or other data transmission methods.
In such embodiments, client-specific rules instruct the price
determination system 115 how and where to access the information
desired for calculating the contracted payment amount and, if
applicable, for processing the payment amount information in
accordance with the benefit coverage and payment rules 155 of the
client group.
[0055] FIG. 2A depicts one embodiment of an eligibility list 135
that may be used by the price determination system 115 to access
information about the patient's 100 eligibility to receive medical
goods and services at the client group's contracted reduced rates.
In some embodiments, possession of the card 205 confers eligibility
to participate in the medical plan. In some embodiments, client
group members pay monthly for access to the benefits of the health
plan, and eligibility is determined on a monthly basis. In other
embodiments, eligibility is determined based upon other bases, such
as, for example, upon continued employment by a given employer. In
some embodiments, membership in the client group and eligibility
for the contracted reduced rates of the medical plan is
demonstrated in ways other than by use of the card 105.
[0056] As depicted in FIG. 2A, the eligibility list 135 comprises
information that identifies the patient 100, such as, for example,
a member identification number 205 assigned by the health plan. In
some embodiments, a member's name is used to identify the member.
In some embodiments, membership in the client group may be extended
to an eligible patient's 100 family members, and in such
embodiments the eligibility list 135 may comprise identifying
information about the member who is considered the primary member
210. Information about an effective start date of eligibility 215
to receive the client group's contracted reduced rates and a
termination date of eligibility 220, if any exists, may also be
stored in the eligibility list 135 and may be used by the price
determination system 115 for verifying eligibility and for
calculating the contracted payment amount for the patient
encounter.
[0057] In embodiments where one or more parties or entities other
than the patient 100 in the provider's office 110 is responsible
for paying at least a portion of the payment amount, the price
determination system 115 may also use information in the
eligibility list 135 to correctly apportion responsibility for the
payment. In such embodiments, the eligibility list 135 may also
comprise additional information, such as, for example, a balance
amount remaining towards a medical plan's required deductible
amount 225 and a history 230 of medical claims or other information
useful for calculating and apportioning responsibility for a
contracted payment amount. Information in the eligibility list 135
may be updated as best suits the needs of the client group, and in
various embodiments, the eligibility list 135 is updated daily,
weekly, or monthly.
[0058] FIG. 2B depicts one embodiment of a provider list 140 that
may be used by the price determination system 115 to determine with
which PPO's the provider 110 is affiliated and to verify that the
provider 110 is affiliated with at least one of the PPO's that
comprise the medical plan for the client group. The provider list
140 may also be used to identify a bank account 112 associated with
the provider 110 into which funds as payment for contracted payment
amounts may be deposited. The provider list may also store and
provide other provider-related information as desired by the
individual client groups.
[0059] As depicted in FIG. 2B, the provider list 140 comprises
identifying information 235, which in FIG. 2B is embodied as the
providers' tax identification numbers. Identification information
can also be embodied in different forms, and in some embodiments,
the provider list 140 stores identification for the provider 110 as
well as for a group, such as a hospital or doctor's group, to which
the provider 110 belongs. Bank account information 241 allows for
direct deposit of payment amounts in the provider's bank account
112, and zip code information 242 allows for accurate calculation
of the payment amount when it is based, all or in part, on the
provider's geographic location. The provider list 140 also
comprises a list of the PPO affiliations 240 for each provider 110,
which is used by the price determination system 115, in conjunction
with the priority list 145 that will be described with reference to
FIG. 2C, to identify an appropriate PPO whose fee schedule 150 will
be used to calculate the contracted payment amount, as will be
described in greater detail below with respect to FIGS. 3 and
5.
[0060] As was described above, a medical plan may comprise fee
schedules 150 that have been negotiated with providers 110 by a
plurality of PPO's. As was also described above, a provider 110 is
often affiliated with a plurality of PPO's and may have contracted
with different PPO's to provide goods and services at varying
rates. In one embodiment, in order to know which contracted payment
rate applies to goods or services offered by a provider 110 to a
patient in a given client group, the client group builds its
medical plan as a hierarchy of PPO fee schedules 150 that is
encoded in the priority list 145. Thus, a PPO in the health plan is
assigned a ranking, and providers 110 who serve patients 100 in the
client group agree to accept the fee schedule negotiated with the
health plan's top-ranking PPO, if the provider 110 is affiliated
with the top-ranking PPO, and otherwise with the highest-ranking
PPO with which the provider 110 is affiliated.
[0061] FIG. 2C depicts one embodiment of a priority list 145 that
is used by the price determination system 115 to determine which
fee schedule 150 to use for calculating the contracted payment
amount. As depicted in the example in FIG. 2C, the priority list
145 comprises the list of PPO's 250 whose fee schedules are used by
the health plan, as well as a ranking 245 for each PPO. Using the
priority list 145, along with any applicable rules from the
client-specific benefit coverage and payment rules 155, allows the
price determination system 115 to know what fee schedule 150 to use
to calculate a payment amount when the provider 110 is affiliated
with more than one PPO, as is often the case.
[0062] In some embodiments, the PPO affiliations 240 associated
with a given provider identification 235 are organized in an
ordered format. For example, in embodiments where the PPO's in the
PPO affiliation list 240 are listed by business name, the PPO's may
be listed alphabetically by business name. In embodiments where the
PPO's in the list 240 are given an identification number, the PPO's
in the list can be listed, for example, in ascending or descending
numerical order. In the embodiment shown in FIG. 2B, the PPO's are
identified by alphanumeric code names (for example, PPO-1, PPO-2),
and the lists of PPO affiliations 240 are ordered in ascending
order of the numeric portion of the code names. Thus, the PPO
affiliation list 240 for the provider 110 with tax identification
number "22-222-22" begins with PPO-2, PPO-7, and PPO-22. The PPO
affiliation list 240 for the provider 110 with tax identification
number "44-444-44" begins with PPO-2, PPO-3, and PPO-7. In other
embodiments, the PPO affiliations list 240 may be stored in an
unordered format. The PPO affiliations list 240 for provider
"22-222-22" is compared with the ranked list of PPO's 250 in the
priority list 145 to ascertain the highest ranking PPO amongst the
affiliates of provider "22-222-22." In the priority list 145 of
FIG. 2C, the top ranking PPO is PPO-3, follow next by PPO-2 in
second place, and PPO-7 in third place.
[0063] For example, to continue with our example of provider
"22-222-22" from FIGS. 2B and 2C, in one embodiment, the PPO
affiliations 240 from the provider list 140 are searched first for
the presence of the top-ranking PPO. In this example, the top
ranking PPO in the priority list is PPO-3, and the PPO affiliations
list 240 for provider "22-222-22" can be searched for the presence
of a listing for PPO-3.
[0064] If the PPO affiliations list 240 is ordered, as it is in
FIG. 2B, a computer-implemented search beginning at the start of
the list 240 can attempt to find PPO-3 in the list 240 and can
determine, once the listing for PPO-7 has been reached without
encountering a listing for PPO-3, that PPO-3 does not exist in the
list 240. Therefore, the search for PPO-3, the highest ranking PPO
in the priority list 145, among the PPO affiliations 240 of
provider "22-222-22" need not be continued.
[0065] If the PPO affiliations list 240 is unordered, then a
computer-implemented search can be made of the entire list 240, to
see if PPO-3 is present in the list.
[0066] If a search determines that the highest-ranking PPO is not
present amongst the affiliations 240 of provider "22-222-22," then
a new search can be initiated, this time for the second-ranking PPO
from the priority list. In the examples of FIG. 2C, the
second-ranking PPO is PPO-2, and a search of the PPO affiliations
list 240 for provider "22-222-22" reveals that PPO-2 is amongst the
PPO's listed for provider "22-222-22." Thus, PPO-2 is the
highest-ranking PPO affiliation for provider "22-222-22," and the
fee schedule 150 associated with PPO-2 will be used to determine
the negotiated payment amount for the encounter.
[0067] Continuing with the example embodiments of FIGS. 2B and 2C,
if the provider 110 with tax identification number "44-444-44"
submits a price determination request to the same health plan for
an identical encounter, the PPO-2 fee schedule 150 is not used,
although provider "44-444-44" is also affiliated with PPO-2. The
fee schedule 150 for PPO-3 is used, because when the PPO
affiliations for provider "44-444-44" are searched for PPO-3, the
highest-ranking PPO in the priority list 145, the search reveals
that provider "44-444-44" is affiliated with PPO-3. Thus, PPO-3 is
the highest-ranking PPO in the health plan with which provider
"44-444-44" is affiliated, and the fee schedule for PPO-3 is used
to determine the negotiated payment amount for the encounter.
[0068] Each client group's health plan may comprise a different set
of PPO fee schedules and may order them in a different hierarchy.
Thus, provider "22-222-22" and provider "44-444-44" may submit
price determination requests for the same encounters as in the
first example above to another client group's health plan, and may
have their negotiated payment amounts calculated according to
different fee schedules than those that were used in the first
example. For example, if a health plan's priority list 145
comprises PPO-7, PPO-22, and PPO-45 as the three top-ranked PPO's,
then a search of the affiliated PPO lists 240 for provider
"22-222-22" and for provider "44-444-44" reveals that they both are
affiliated with PPO-7, and they will thus both have their payment
amounts calculated using the fee schedule 150 of PPO-7.
[0069] In another embodiment of a priority list 145, the list 145
for a given health plan may provide a ranking that is
geographically based. For example, the priority list 145 may
specify, for providers 110 in a geographical area defined by a
grouping of postal zip codes, that a certain ranking of PPO's be
used for selecting a fee schedule 150, while for providers 110 in
another geographical area, defined by a different grouping of
postal zip codes, another ranking of the PPO's be used to select
the fee schedule 150. This type of geographically-based priority
list 145 can reflect the fact that many PPO's are also
geographically based, which is to say that they represent a network
of providers within a limited geographical area, rather than being
a national network with providers spread across the country. Using
this type of embodiment, a health plan can, for example, structure
its priority list 145 to always give highest ranking to locally
based PPO's. When a provider 110 requests a price determination,
the priority list 145 is consulted using the provider's 110 zip
code in order to access the health plan's ranking of PPO's for that
zip code. Thus, the highest-ranking PPO amongst the provider's 110
PPO affiliations 240 can be ascertained, and the appropriate fee
schedule 150 for the price calculation can be located.
[0070] In another embodiment, in locations where such a health plan
structure is permissible by law, a health plan may structure its
priority list 145 to select the PPO fee schedule 150 that reflects
the lowest cost to the patient or other payor. In such an
embodiment, the priority list 145 may be organized by CPT code,
such that for a given CPT code, or grouping of CPT codes, a ranked
priority list 145 of PPO's is provided to reflect the PPO's that
have negotiated the lowest payment amount for the given services or
goods. With this type of embodiment, when a provider 110 requests a
price determination, the priority list 145 is consulted using the
CPT code identified by the provider 110 as describing the patient
encounter for which pricing is requested. Thus, the health plan's
cost-based ranking of PPO's for the given service or goods can be
used to determine the appropriate fee schedule 150 to use for the
payment amount calculation.
[0071] Three embodiments of PPO hierarchies and their associated
priority lists have been described as examples. Other hierarchy
systems are possible and priority lists 145 to suit the hierarchy
systems can be created, as will be appreciated by one of ordinary
skill in the art.
[0072] FIGS. 2A, 2B, and 2C depict examples of data structures that
can be used to store data for the price determination system 115.
However, the data used by the price determination system 115 may
also be stored as other types of flat files, as relational or
object-oriented data structures, or as other appropriate
structures. As will be familiar to one of ordinary skill in the
art, the structure, organization, and content of the data may be
embodied in different forms to serve the various embodiments of the
medical payment system, without departing from the spirit of the
medical payment system described herein. In some embodiments, some
or all of the eligibility list 135, the provider list 140, and the
priority list 145 are implemented as computer modules.
[0073] FIG. 3 is a flowchart that depicts one embodiment of a
medical payment system 300 that allows a medical provider 110 to
contact a price determination system 115 and to receive from the
price determination system 115 the correct negotiated payment
amount for a patient encounter. From a start state, the medical
payment system 300 proceeds to state 310, in which the medical
provider 110 contacts the price determination system 115. In one
embodiment, the provider 110 contacts the price determination
system 115 by dialing a phone number printed on the patient's 100
medical plan card 105 and by thereby being connected to an
interactive voice response system (IVRS) associated with the price
determination system 115. In one embodiment, the telephone number
is not printed on the medical plan card 105, and the provider 110
has access to the number for connecting to the IVRS from another
source. In one embodiment, the provider 110 contacts the price
determination system 115 by dialing a phone number printed on the
patient's 100 medical plan card 105 and speaking to an operator. In
one embodiment, the provider 110 contacts the price determination
system 115 using a computer network. In other embodiments, other
methods of communication, such as dedicated phone lines or wireless
communications systems, are used by the provider 110 to contact the
price determination system 115.
[0074] Moving on to state 320, once the medical provider 110 has
contacted the price determination system 115, the medical provider
110 inputs information about the patient encounter for which the
provider 110 wishes to receive a contracted payment amount. In one
embodiment where the provider 110 has contacted the price
determination system's 115 IVRS via telephone, the provider 110 is
prompted by oral instructions transmitted from the IVRS to input
the patient encounter information using the keypad on the
telephone. In one embodiment, the IVRS prompts the provider 110 to
input the patient encounter information orally, and the price
determination system 115 uses a voice recognition system to encode
the information into a format usable by the price determination
system 115. In other embodiments, the provider 110 inputs the
patient encounter information using a computer keyboard or other
computer input system. FIG. 4 describes in greater detail one
embodiment of an encounter information input system.
[0075] Moving on to state 330, once the medical provider 110 has
input the patient encounter information, the price determination
system 115 identifies the appropriate fee schedule for the
encounter. In state 340, the price determination system 115 uses
information from the identified fee schedule to calculate the
contracted payment amount for the encounter. The actions of states
330 and 340 are described in greater detail with reference to FIG.
5 below.
[0076] Moving on to state 350, once the price determination system
115 has calculated the contracted payment amount for the encounter,
the price determination system 115 communicates the payment amount
to the provider 110 and to any parties or entities responsible for
paying the provider, as indicated by the benefit coverage and
payment rules 155 that were described with reference to FIG. 1. In
one embodiment, where the provider 110 communicates with the price
determination system 115 using an IVRS, the price determination
system 115 transmits an oral message over the telephone, informing
the provider 110 of the payment amount. In one embodiment, the
price determination system 115 may also offer an option of having a
record of the calculated payment amount faxed to the provider's
office 110 so that the provider 110 can have a paper copy of the
information exchanged and the calculated payment amount.
[0077] Communicating the calculated payment amount to the
provider's office 110 at the time of service allows the provider
110 to present an accurate bill for the encounter to the patient
100 at the time of service, thereby enabling the patient 100 to pay
the provider 110 before leaving the office. This capability
represents a great improvement over current medical payment systems
in which the provider 110 may typically wait three to six months to
receive payment for an encounter. In one embodiment, as a condition
of receiving the medical plan card 205 and access to the reduced
rates that it represents, the patient 100 agrees to pay his or her
portion of the calculated payment amount, in full or as otherwise
agreed upon with the provider 110, at the time of service.
[0078] When one or more parties or entities, such as, for example,
a third party payor 190, a purse 192, or a medical credit card
account 195, is responsible for paying all or part of a calculated
payment amount, the price determination system 115 may be
instructed by the benefit coverage and payment rules 155 to submit
a claim or a notification to the one or more responsible parties or
entities. Communication with the responsible parties or entities
190, 192, 195 may take place via a dedicated high-speed,
high-volume data line, via telephone connection, via computer
network connection, or via another communications method.
Instructions regarding the content of the claim or notification
communication may be provided to the price determination system 115
by the benefit coverage and payment rules 155, so that the price
determination system 115 is able to accommodate a variety of types
of responsible parties and entities 190, 192, 195. When instructed
by the benefit coverage and payment rules 155, the price
determination system 115 can wait for feedback, such as a
confirmation, from the responsible parties or entities 190, 192,
195 and can transmit an appropriate message to the provider's
office 110 using the IVRS, the fax, or other chosen communications
method. Such an appropriate message may, in some embodiments, be a
simple confirmation of the actions taken by the price determination
system 115, and may, in some embodiments, provide information about
a portion of the payment amount still remaining for the patient 100
to pay.
[0079] Other embodiments can allow the price determination system
115 to process the calculated payment amount in different ways. In
one embodiment, claims for submission to responsible parties 190,
192, 195 for payment are batched and are sent to the responsible
parties once a day, or as is otherwise deemed desirable. In one
embodiment, information is stored in a table with the
client-specific data 120 that describes a price determination
request for a given encounter and information about the amount of
savings received by the patient 100 over the provider's standard
billing rate for the encounter. Such information may be provided to
the client group or to another interested, authorized party for
assessing the value of the medical plan to its members.
[0080] The flowchart of FIG. 3 has depicted one embodiment of a
medical payment system. As will be clear to one of ordinary sill in
the art, other embodiments of the medical payment system may be
implemented that arrange the states of the system in other
configurations, that add or delete states as appropriate, that
divide the system into different states, or that exhibit a
combination of these changes without departing in spirit from the
medical payment system described herein.
[0081] FIG. 4 presents a flowchart that depicts one embodiment of
an interactive voice response system (IVRS) 400 that can be used by
a price determination system 115 to receive encounter information
from a provider 110 and to transmit an associated calculated
payment amount back to the provider 110 and, if appropriate, to
other associated parties and/or entities 190, 192, 195.
[0082] In one embodiment, communication from the provider 110 to
the IVRS 400 is carried out using a touch-tone telephone keypad,
and communication from the IVRS 400 to the provider 110 is carried
out by recorded voice messages. Allowing the provider 110 to use
the telephone keypad to enter the encounter information, which, in
one embodiment, is encoded numerically, provides an accurate,
quick, and easy-to-use method for inputting the encounter
information. Using the keypad to enter encounter information draws
upon knowledge that is common to workers in a medical provider's
office 110 and does not require computer literacy or computer
equipment on the part of the provider 110. Configuring the IVRS 400
to communicate verbally with the provider 110 in order to convey
both instructions for use of the system and the calculated payment
amount provides a familiar, easily understandable method for
communicating with the provider 110. In one embodiment, additional
communication from the IVRS 400 to the provider 110 may be carried
out by fax transmission, especially at the end of the price
determination for providing a summary in printed format of the
price determination for the encounter.
[0083] In other embodiments, other methods of communication may be
implemented for communications from the provider 110 to the price
determination system 115, from the price determination system 115
to the provider, and from the price determination system 115 to any
other relevant party or entity 190, 192, 195.
[0084] For the embodiment depicted in FIG. 4, beginning at state
402, the IVRS 400 greets the provider 110. Moving on to state 406,
the IVRS 400 prompts the provider to enter the patient's 100 member
identification number. In one embodiment, the patient's 100 member
identification number is assigned by the client group's health plan
and is printed on the patient's 100 medical plan card 105. In one
embodiment, the IVRS 400 prompts the provider to enter identifying
information other than a member identification number for the
patient 100. Having access to identifying information for the
patient 100 allows the price determination system 115 to verify the
patient's 100 eligibility for the medical plan and, where
applicable, allows the system 115 to access information about the
patient's deductible balance remaining and prior claim history or
other relevant patient-specific information.
[0085] Moving on to state 410, the IVRS 400 prompts the provider
110 to enter identifying information for the provider 110. In the
embodiment shown in FIG. 4, the provider's federal tax
identification number is used as a readily available and
standard-formatted identifier. In other embodiments, other forms of
identification may be used for identifying the provider 110.
Identifying the provider 110 allows the price determination system
115 to access information about the provider's 110 PPO
affiliations, the provider's bank account information 112, and the
provider's contact information, geographic location, and other
relevant provider-specific information.
[0086] In the embodiment shown in FIG. 4, the IVRS 400 proceeds to
state 414, where the patient 100 identification information and the
provider 110 identification information are sent to a host
processor. In embodiments where the telephone number dialed by the
provider 110 automatically connects the provider 110 to the
client-specific data 120 indexed by the client group access number
130, having the patient 100 identification information allows the
processor to begin accessing stored data that is used to verify
patient 100 eligibility, so that the provider 110 can be notified
promptly if the patient 100 is determined not to be eligible for
the benefits of the client group's health plan.
[0087] Being connected to the client-specific data 120 also allows
the processor to access the health plan's hierarchy of PPO's, as
expressed in its priority list 145. Based on the type of PPO
hierarchy used by the health plan, having the provider 110
identification information may allow the processor to begin
locating the fee schedule 150 that will be used by the price
determination 115 system for calculating the payment amount. For
example, for health plans with PPO hierarchies similar to the
example illustrated in FIG. 2C, having access to the provider 110
identification information allows the price determination system
115 to gain access to the provider's 110 list of PPO affiliations
240. Comparing this list 240 to the priority list 145 allows the
price determination system 115 to identify the appropriate fee
schedule 150.
[0088] In one embodiment, to identify the appropriate fee schedule
150, the price determination system 115 determines if the health
plan's highest-ranking PPO is among the provider's 110 affiliates.
If so, the processor locates and loads the associated fee schedule
150. If not, the price determination system 115 identifies the
second-ranking PPO in the health plan's priority list 145 and once
again makes a comparison with the provider's 110 PPO affiliations
list 240. The price determination system 115 determines if the
second-ranking PPO is the amongst the provider's affiliates. If so,
the second-ranking PPO is therefore the highest ranking PPO
available amongst the provider's 110 affiliations 240, and its fee
schedule 150 is used for price determination. If it is not, this
search process continues until the highest-ranked PPO that is both
on the priority list 145 and on the provider's PPO affiliation list
120 is located.
[0089] Once the appropriate fee schedule 150 is identified, the
price determination system 115 can already, "in the background,"
access the fee schedule 150, which will be used to calculate a
payment amount for any procedure codes entered for the encounter.
Fee schedules 150, which typically comprise a large volume of
complex data, can sometimes be unwieldy and slow to load, and
loading the fee schedule "in the background" while the provider 110
continues to communicate with the IVRS thus enhances the response
speed of the system.
[0090] Other embodiments of the priority list 145 also allow for an
"in the background" loading of the fee schedule.
[0091] For example, in embodiments where the PPO hierarchy is
geographically-based, and where the provider list 140 comprises zip
code information 242 for the provider 110, having access to the
provider identification 235 allows the price determination system
115 to ascertain the provider's zip code 242 and to use that
information to locate the associated PPO priority list 145. As with
the previous example, having access to the priority list 145 and to
the provider's 110 list of PPO affiliations 240 allows the price
determination system 115 to identify the appropriate fee schedule
150.
[0092] In one embodiment in which the priority list 145 is based at
least in part on the CPT codes entered by the provider 110,
locating and loading the appropriate fee schedule 150 is deferred
until CPT information is entered that will allow the appropriate
fee schedule 150 to be located.
[0093] Moving on to state 418, in the embodiment shown in FIG. 4,
the IVRS 400 prompts the provider 110 to enter information about a
medical diagnosis associated with the encounter. One commonly used
numeric code for communicating about medical diagnoses is called
the International Classification of Diseases (9.sup.th Edition)
code (ICD-9), and in one embodiment, the diagnosis information is
entered using an ICD-9 code. In one embodiment, providing the price
determination system 115 with information about the diagnosis
associated with the encounter allows the system 115 to accurately
determine coverage and payment levels for claims, such as medical
insurance claims, that are based at least in part on diagnosis
information.
[0094] Moving on to state 422, the IVRS 400 determines whether or
not the host was able to locate the appropriate fee schedule 150
for the encounter. If the appropriate fee schedule 150 was not
found, the IVRS 400 proceeds to state 426, where the provider 110
is transferred to a live customer service representative for
completion of the price determination request. If the appropriate
fee schedule 150 has been located, the IVRS 400 proceeds to state
430 where the fee schedule 150 is accessed.
[0095] Moving on to state 437, the IVRS 400 prompts the provider
110 to enter information about a medical good or service associated
with the patient encounter. One commonly used numeric code for
communicating about medical goods and services is the Common
Procedure Terminology (CPT) code. A CPT Modifier Code for use in
conjunction with the CPT code can be used to expand the expressive
capabilities of the CPT codes. In one embodiment, the medical goods
or services information is entered using a CPT code and, if
desired, a CPT modifier code. Providing the price determination
system 115 with information about the medical goods or services
associated with the encounter allows the system 115 to accurately
determine a contracted payment amount.
[0096] In the embodiment shown in FIG. 4, the IVRS 400 prompts the
provider 110 to enter additional information in response to
inputted CPT codes for procedures associated with surgery,
anesthesia, laboratory work, and radiology, as is described with
reference to states 438-444. CPT codes are often grouped
numerically into five classes that allow for easy identification of
surgery, anesthesiology, laboratory, and radiology procedures. In
other embodiments, other CPT codes may receive special treatment,
as suits the preferences of the client group's medical plan.
[0097] Referring first to state 438, the IVRS 400 determines if the
CPT code entered by the provider 110 in state 437 is a surgery
code. If the CPT code is determined to be a surgery code, the IVRS
400 proceeds to state 439, where the provider 110 is prompted to
indicate if the surgery is an assisted surgery. In one embodiment,
if the provider 110 indicates that the surgery was assisted,
meaning that the provider 110 served as an assistant surgeon in the
surgery, then the price determination system 115 is given this
information. In one embodiment, the information is requested
because an assistant surgeon is typically compensated at a
percentage of the allowed payment amount for the primary surgeon.
In state 440, the provider 110 is prompted to enter the provider's
standard billed amount for the surgery, rounded to the nearest
dollar, and the IVRS 400 proceeds to state 445, where the provider
is prompted to indicate whether there are more CPT codes to enter
in association with this encounter.
[0098] Returning to state 439, if the provider 110 responds that
there are multiple surgery codes to enter, then the IVRS 400
proceeds to state 445, where the IVRS 400 cycles back to state 437
and the provider 110 is prompted to enter another CPT code. In one
embodiment, the price determination system 115 has been alerted at
this point that subsequent surgery codes entered are for secondary
surgeries performed in conjunction with a primary surgery, because
secondary surgeries are typically compensated at a lower payment
amount than primary surgeries.
[0099] If, in state 438, the IVRS 400 determines that the CPT code
entered in state 437 is not a surgery code, the IVRS 400 proceeds
to state 441, where the IVRS 400 determines if the CPT code entered
in state 437 is an anesthesia code. If the CPT code is determined
to be an anesthesia code, the IVRS 400 proceeds to state 442, where
the provider 110 is prompted to enter the length of time of the
anesthesia procedure in whole minutes. Entering the time length for
the anesthesia procedure can be accomplished easily using a
telephone keypad and allows for proper calculation of the
contracted payment amount for an anesthesia procedure.
[0100] If, in state 441, the IVRS 400 determines that the CPT code
entered in state 437 is not an anesthesia code, the IVRS 400
proceeds to state 443, where the IVRS 400 determines if the CPT
code entered in state 437 is a laboratory or radiology code. If the
CPT code is determined to be a laboratory or radiology code, the
IVRS 400 proceeds to state 444, where the provider 110 is prompted
to indicate by means of CPT modifier code 165, whether the price
determination request is for service rendered by a technician, such
as a blood draw, which is considered a "technical component" and is
compensated at one rate, or is for service rendered by a physician,
such as analysis of blood test results, which is known as a
"professional component" and is compensated at another rate.
[0101] If, in state 443, the IVRS 400 determines that the CPT code
entered in state 437 is not a laboratory or radiology code, the
IVRS 400 proceeds to state 445, where the IVRS 400 prompts the
provider 110 to indicate whether the provider 110 has more CPT
codes to enter in association with the patient encounter for which
a payment amount is being requested.
[0102] If, in state 445, the provider 110 indicates that there are
additional CPT codes to be entered in conjunction with the payment
amount calculation request for the current patient encounter, the
IVRS 400 returns to state 437 where the IVRS 400 prompts the
provider 110 to enter a CPT code. The IVRS 400 continues to cycle
through states 437-445 until the provider 110 indicates that there
are no further CPT codes to enter in association with the current
payment amount request.
[0103] When, in state 445, the provider 110 indicates that there
are no further CPT codes to enter in association with the current
payment amount request, the IVRS 400 proceeds to state 470, where
the IVRS 400 transmits the information that was received from the
provider 110 about the patient 100, the provider 110, the diagnosis
(ICD-9), and the goods and services (CPT's) associated with the
encounter to a host processor for the price determination system
115.
[0104] In one embodiment, the IVRS 400 proceeds to state 474 where
the IVRS 400 plays a message indicating the calculated pricing
information to the provider 110 over the telephone. In the
embodiment shown in FIG. 4, the IVRS 400 may additionally or
alternatively fax the calculated pricing information to the
provider 110.
[0105] Moving on to state 478, the price determination system 115
sends the calculated payment information and any associated
information indicated by the benefit coverage and payment rules 155
to any responsible parties and/or entities indicated in the benefit
coverage and payment rules 155 as was described with reference to
FIG. 1.
[0106] Moving on to state 482, the IVRS 400 prompts the provider
110 to indicate whether there are more claims to price for this
patient. If the provider 110 indicates that there are one or more
claims to price, the IVRS 400 proceeds to state 437, where the
provider 110 is again prompted to enter a CPT code and to proceed
as was described above. If, in state 482, the provider 110
indicates that there are no more claims to price for the patient
100, the IVRS proceeds to state 486, where the IVRS 400 indicates
to the provider 400 that the interaction is completed, and the
communication is terminated.
[0107] The flowchart of FIG. 4 depicts one embodiment of an
encounter information input system. As will be clear to one of
ordinary skill in the art, other embodiments of the encounter
information input system may be implemented that arrange the states
of the system in other configurations, that add or delete states as
appropriate, that divide the system into different states, or that
exhibit a combination of these changes without departing in spirit
from the encounter information input system described herein.
[0108] FIG. 5 is a flowchart that depicts one embodiment of a
method 500 that can be carried out by a price determination system
115 to determine a contracted payment amount for a patient
encounter. The embodiment shown in FIG. 5 corresponds generally to
states 330 and 340 of the medical payment system 300 described with
reference to FIG. 3 above.
[0109] The method 500 of FIG. 5 begins in state 510 where the price
determination system 115 verifies the eligibility of the patient
100 to receive the benefits of the medical plan associated with the
client group access number 130. In one embodiment, the price
determination system 115 accepts member identification information
about the patient 100 from the provider 110 and uses the
identification information to access eligibility information about
the patient 100 stored in an eligibility list 135, as was described
in greater detail with reference to FIG. 2A. For example, in
embodiments in which information about the patient's effective date
215 of coverage and termination date 220 is stored in the
eligibility list 135, the price determination system 115 verifies
that the current date is later than the effective date 215 and that
the current date is earlier than the termination date 220, if any
termination date 220 is listed.
[0110] Once the price determination system 115 determines that the
patient 100 is eligible to receive the benefits of the medical
plan, the price determination system 115 proceeds to state 520 of
the method 500, in which the price determination system 115 uses
the medical provider 110 identification information entered by the
provider 100 to identify the provider's 100 PPO affiliations. In
one embodiment, the price determination system 115 uses the
provider list 140, as was described in greater detail with
reference to FIG. 2B, to identify the provider's 110 PPO
affiliations.
[0111] Proceeding on to state 530 of the method 500, the price
determination system 115 uses the PPO affiliation information
accessed in state 520 together with information stored in the
priority list 145, as was described in greater detail with
reference to FIG. 2C, to identify which of the provider's 100
affiliated PPO's is given the highest priority according to the
priority list 145. This information can be used to identify the fee
schedule 150 that is to be used for calculating the payment amount.
Basically, the PPO affiliations negotiated by the provider 110 are
identified, the hierarchy of the health plan's PPO's is identified,
and the two are compared in order to determine which of the PPO's
affiliated with the provider 110 has the highest ranking in the
health plan's hierarchy.
[0112] In various embodiments, identifying which of the provider's
110 affiliated PPO's is given the highest priority can be carried
out in different ways, depending on the organization, structure,
and content of the priority list 145 and of the list of PPO
affiliations 240 for each provider 110. For example, whether the
provider's 110 PPO affiliations are stored in an ordered or an
unordered format, as well as the type of data structure used for
their storage, will affect the method used for searching for and
locating the given provider's 110 most highly-ranked PPO, as will
be familiar to a practitioner of ordinary skill in the art. One
simple example of such a search was described with reference to
FIGS. 2B and 2C.
[0113] Furthermore, the type of hierarchical organization of PPO's
that is used to form the client group's health plan will affect the
method used in state 530 to determine which PPO's fee schedule 150
is to be used for calculating the payment amount due to the
provider 110.
[0114] For example, as was described with reference to FIG. 2C, in
embodiments where the health plan is organized such that for each
geographical location served, a different ranking of the PPO's is
used, then searching for the highest-ranking PPO may comprise
identifying the zip code 242 associated with the provider 110 and
identifying the portion of the priority list 145 associated with
that zip code.
[0115] In other embodiments, one ranking of PPO's may be used for
all geographical areas except for one area, in which, for example,
a self-insuring employer has negotiated special rates with medical
providers and for which another ranking exists. In such an
embodiment, the benefit coverage and payment rules 155 may instruct
the price determination system 115 to use the zip code 242 of the
provider 110 who is submitting a price determination request to
access the desired ranking of PPO's in the priority list 145.
[0116] As was also described with reference to FIG. 2C, in some
embodiments where such arrangements are permissible, the health
plan is organized such that the payment amount negotiated by the
PPO that offers the lowest price for the services or goods
associated with the patient encounter is the amount used as the
contracted amount. In such embodiments, searching for and locating
the appropriate fee schedule comprises identifying the CPT code or
other procedure/goods identifier associated with the patient
encounter and identifying the portion of the fee schedule 150 that
gives a ranking of PPO's for that procedure identifier.
[0117] Procedure identifiers such as CPT codes may also be relevant
to the search for an appropriate fee schedule 150 in embodiments
where a given PPO does not provide a negotiated rate for the
services or goods associated with the patient encounter. For
example, a given PPO may not have negotiated a payment amount for
eye examinations with its affiliated providers. Thus, even if the
given PPO is listed in the priority list 145 as having the highest
ranking in general, for patient encounters that involve an eye
examination, the fee schedule associated with the PPO that has the
next highest ranking and that does provide a contracted rate for
eye examinations will be used. As will be familiar to a
practitioner of ordinary skill in the art, the priority list 145
can be modified to express such a hierarchy.
[0118] Other embodiments may use other methods and information
sources to search for an appropriate fee schedule, as encoded in
the instructions of the benefit coverage and payment rules 155. For
example, in one embodiment, a client group may choose to give the
highest ranking to the PPO, from amongst those that make up its
health plan, that contracts with the largest number of providers,
and to rank the other PPO's in its health plan according to the
number of providers in their network, as well. Information about
the number of contracted providers participating in each PPO's
network may be provided to the price determination system 115 on a
daily, weekly, monthly, yearly or other basis, so that the priority
list 145 in such an embodiment may be kept up-to-date.
[0119] Handling exceptions and anomalies in the selection of fee
schedule 150 for use in price determination can be carried out in a
variety of ways, as expressed by the benefit coverage and payment
rules 155 for a given client group. In some embodiments, if a
provider 110 does not appear in the client group's provider list
140, or if the identified provider 110 has no associated PPO
affiliations that appear in the priority list 145, then the price
determination request submitted by telephone, computer, or other
communications method is forwarded to a human representative for
price determination. In some embodiments, the price determination
request is rejected, and a message is transmitted to the provider's
office 110 that no payment amount for the encounter can be
calculated using the price determination system 115.
[0120] In some embodiments, the benefit coverage and payment rules
155 for a given client group specify a default method of handling
such anomalies or exceptions. In one embodiment, a default flat fee
for each CPT code may be specified. In another embodiment, a fixed
percentage of the provider's standard billing rate for the given
service or good may be specified. In such an embodiment, the IVRS
or other communications method may need to prompt the provider 110
to enter the standard billing rate for the given service or good.
In other embodiments, exceptions and anomalies are handled using
other methods that will be familiar to one of ordinary skill in the
art.
[0121] Proceeding to state 540 of the method 500, the price
determination system 115 accesses the fee schedule 150 for the PPO
that was identified in state 530 as being the PPO with the highest
priority from amongst the provider's 110 PPO affiliations. In one
embodiment, the price determination system 115 uses the fee
schedule 150 to determine the contracted calculation methodology
agreed upon by the provider 110 and the provider's highest priority
PPO for the medical goods and/or services with the CPT codes input
by the provider 110 for the patient encounter.
[0122] Once the calculation methodology agreed upon by the provider
110 and by the PPO has been identified, the price determination
system 115 proceeds to state 550 of the method 500 and uses the
identified calculation methodology to calculate the contracted
payment amount for the goods and services identified by the
provider 100 as being associated with the patient encounter. In
some embodiments, the CPT information 160 stored in the price
calculation data 125 is accessed to identify the multiplier values
for the entered CPT codes, as was described with reference to FIG.
1. In some embodiments, zip code information 180 and/or Medicare
payment rate information 175 is accessed in order to calculate the
contracted payment amount for the encounter.
[0123] Once the contracted payment amount has been calculated, the
medical payment system 300 of FIG. 3 can use the payment amount
information together with information stored in the client group's
benefit coverage and payment rules 155 to apportion, amongst one or
more parties or entities 100, 190, 192, 195, the responsibility for
paying the payment amount to the provider 110. The medical payment
system 300 can further communicate with the one or more parties or
entities 100, 190, 192, 195 in order to notify them of the portion
of the payment amount for which they are responsible to pay.
[0124] The flowchart of FIG. 5 has depicted one embodiment of a
method to determine a negotiated payment amount for a patient
encounter. As will be clear to one of ordinary skill in the art,
other embodiments of the payment amount determination method may be
implemented that arrange the states of the system in other
configurations, that add or delete states as appropriate, that
divide the system into different states, or that exhibit a
combination of these changes without departing in spirit from the
payment amount determination method described herein.
[0125] For ease of explanation, some simplifying assumptions have
been made in the foregoing detailed description. For example,
one-to-one correspondences have been assumed between the provider
110 and the provider bank 112, between a client group and the
associated medical plan, and between a PPO and the associated
priority list. Thus, for purposes of this description, for example,
sending a payment to a provider's bank account 112 is equivalent to
sending payment directly to the provider 110. Similarly, for
purposes of this description, because the aspect of interest with
respect to the client group is the medical plan that it offers its
members, the terms client group and medical plan may be used
interchangeably in some instances. Furthermore, the one-to-one
correspondence assumed in this description for ease of explanation
implies that a hierarchy or priority list of PPO's may also be seen
as a hierarchy or priority list of the associated fee schedules. In
other embodiments, these one-to-one correspondences may not hold
true without departing from the spirit of the medical payment
system described herein.
[0126] While certain embodiments of the inventions have been
described, these embodiments have been presented by way of example
only, and are not intended to limit the scope of the inventions.
Indeed, the novel methods and systems described herein may be
embodied in a variety of other forms; furthermore, various
omissions, substitutions and changes in the form of the methods and
systems described herein may be made without departing from the
spirit of the inventions. The accompanying claims and their
equivalents are intended to cover such forms or modifications as
would fall within the scope and spirit of the inventions.
* * * * *