“Cob Underpayment Detection” in Patent Application Approval Process

By a News Reporter-Staff News Editor at Politics & Government Week -- A patent application by the inventor McMakin, Emily H. (Nashville, TN), filed on January 21, 2014, was made available online on July 30, 2015, according to news reporting originating from Washington, D.C., by VerticalNews correspondents.

This patent application has not been assigned to a company or institution.

The following quote was obtained by the news editors from the background information supplied by the inventors: "The present invention generally relates to billing and payment systems, and more particularly to a method of obtaining payment for services such as health care or medical services which are covered by a third party, e.g., an insurance carrier.

"Doctors, hospitals and other health care service providers constantly struggle with patients and insurance companies to see that they have been fairly and properly paid for their services. Insurance claims and reimbursements can get even more complicated when there are multiple insurance carriers which might cover a particular service for a patient. For example, in America many people are covered by a primary insurance carrier (i.e., commercial) and are also covered by a secondary carrier, possibly a government agency such as Medicare or Medicaid. Medicare is a federally administered system of health insurance available to persons aged 65 and over, and certain younger people with disabilities. Medicaid is a federal and state funded health care program for low-income Americans.

"The amounts payable to a service provider, and from whom they are payable, depend upon arrangements not only between the service provider and patient, but also between the carrier and patient, and between the service provider and carrier. The patient will typically pay a portion of the cost of services to the service provider directly, as a co-pay or part of a deductible in the agreement between the patient and the service provider. The service provider may have contracts with carriers which set different amounts for a particular service. In order to ensure compliance with these various terms, methods and systems have been devised which provide for coordination of benefits (COB). For example, U.S. Pat. No. 7,904,305 discloses a method wherein a provider compares claim data processed by an insurance claim processor with the claim data originally submitted, generates comparison data indicating whether the original claim data has been processed in accordance with predetermined claim processing rules, and retransmits revised claim data as appropriate. To avoid the rejection of medical insurance claim data, the system compares a diagnostic code with associated procedure codes and compares the procedure codes with associated supply codes using predetermined processing rules to determine whether they are properly associated.

"U.S. Pat. No. 8,321,243 illustrates a system for the coordination of benefits when a patient is associated with at least two payers which generates a primary claim request based upon the identified product and the patient, and generates a COB claim request for the second payer based on a received first adjudicated reply associated with the primary claim request. The system is particularly advantageous for dual or multiple coverage situations, where a healthcare provider must submit claims to each benefit provider separately and inform providers of amounts that have been paid by previous providers, since such individual claim submissions are otherwise time consuming for the healthcare provider and may be susceptible to inaccuracies as employees of the healthcare provider submit multiple claim requests.

"U.S. Patent Application Publication No. 2005/0033604 relates to a claims settlement system using real-time interactions to submit a claim, receive a predetermined fee schedule based on a patient's relationship to a provider, and automatically authorize a transfer of funds with established guidelines. The system provides asynchronous, real-time distributed computing between insurers and providers.

"U.S. Patent Application Publication No. 2007/0033070 describes an automated collection system which captures a service rendered by a provider, determines a relationship between a third party payer and the provider that defines a preliminary allowed amount to be collected by the provider, and determines a first portion of the preliminary allowed amount that is to be collected from the service recipient.

"U.S. Patent Application Publication No. 2013/0110539 shows a system for processing healthcare claims and remittances which searches a database for previously received claims corresponding to a patient identifier to determine if any claims are associated with a third party payer and, based on the result of a duplicate claim edit or a third party liability edit, submits the received claim to a payer. This approach overcomes problems resulting from the manual processes and the lack of transparency between billing and adjudication systems. A clearinghouse portal provides communications between providers and payers, and accesses a data warehouse to validate correct coordination of benefits."

In addition to the background information obtained for this patent application, VerticalNews journalists also obtained the inventor's summary information for this patent application: "The present invention is generally directed to a method of managing coordination of benefits for a service provided to a consumer by receiving claim data from a service provider wherein the claim data includes service data associated with the service provided to the consumer and first demographic data associated with the consumer, receiving benefits data from a data warehouse of a first payer wherein the benefits data includes second demographic data and payment information including a payment made by the first payer to the service provider for the service provided, correlating the first demographic data with the second demographic data to identify the payment made by the first payer to the service provider as a possible underpayment, determining that the payment is less than an amount allowable by a second payer for the service provided, by executing fourth instructions in the computer system, and generating a payment request for the difference between the allowable amount and the payment. The first payer may for example be Medicare, in which case the data warehouse may be the HIPAA Eligibility Transaction System database, or the first payer may for example be Medicaid, in which case the data warehouse may be a state Medicaid database. In one implementation the second payer has made no remittance for the service provided to the consumer and the payment request is a request for the difference to be paid by the second payer, and the payment request is further sent to the second payer. In an alternative implementation the second payer has paid the allowable amount to the first payer for the service provided to the consumer and the payment request is a request for the difference to be paid by the first payer, and the payment request is further sent to the first payer. The service provided may a health care service when the consumer is a patient.

"The above as well as additional objectives, features, and advantages of the present invention will become apparent in the following detailed written description.

BRIEF DESCRIPTION OF THE DRAWINGS

"The present invention may be better understood, and its numerous objects, features, and advantages made apparent to those skilled in the art by referencing the accompanying drawings.

"FIG. 1 is a block diagram showing various entities involved in an example of conventional processing for health care service benefits with dual coverage;

"FIG. 2 is a block diagram of a computer system programmed to carry out coordination of benefits (COB) underpayment detection in accordance with one implementation of the present invention;

"FIG. 3 is a chart depicting a global process for COB underpayment detection in accordance with one implementation of the present invention;

"FIG. 4 is a chart illustrating the logical flow for identification of coordination of benefits as part of the global process of FIG. 3 in accordance with one implementation of the present invention; and

"FIG. 5 is a chart illustrating the logical flow for a payment management system as part of the global process of FIG. 3 in accordance with one implementation of the present invention.

"The use of the same reference symbols in different drawings indicates similar or identical items."

URL and more information on this patent application, see: McMakin, Emily H. Cob Underpayment Detection. Filed January 21, 2014 and posted July 30, 2015. Patent URL: http://appft.uspto.gov/netacgi/nph-Parser?Sect1=PTO2&Sect2=HITOFF&u=%2Fnetahtml%2FPTO%2Fsearch-adv.html&r=2645&p=53&f=G&l=50&d=PG01&S1=20150723.PD.&OS=PD/20150723&RS=PD/20150723

Keywords for this news article include: Patents, Legal Issues.

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