Patent Application Titled “Computer Implemented Methods And Systems For Health Plan Design Administration” Published Online (USPTO 20230069388): Patent Application

2023 MAR 16 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- According to news reporting originating from Washington, D.C., by NewsRx journalists, a patent application by the inventor Niemeyer, Mark (O’Fallon, MO, US), filed on August 25, 2021, was made available online on March 2, 2023.

No assignee for this patent application has been made.

Reporters obtained the following quote from the background information supplied by the inventors: “Health plans provide insurance coverage for medical expenditures of enrolled individuals. A health plan “member” as used herein generally refers to the enrolled individual. A “plan sponsor” generally refers to an entity, such as an employer, that pays a portion of the premiums and/or medical claims. A “premium” generally refers to an amount paid in consideration for an entity providing health insurance coverage or the like.

“Traditionally, health plans have created a structure for cost-sharing with the members, herein referred to as a “plan design”. A plan design typically includes one or more of the following: deductibles, copays, coinsurance, coverage limits, and provider networks. A “deductible” generally refers to an amount during a period of time, typically a calendar year, that the member must pay before the health plan pays its share. A “copay” generally refers to a fixed amount that the member must pay on a particular visit or service and the health plan pays the remaining balance. A “coinsurance” generally refers to a percentage of total costs that the member must pay on a particular visit or service and the health plan pays the remaining balance. A “coverage limit” generally refers to a maximum amount a health plan will pay for a particular service or during a period of time, typically the lifetime of member. A “provider network” generally refers to the healthcare providers that the health plan has a contractual agreement on payment rates.

“Health plans typically bifurcate the choices members have for choosing healthcare service providers based upon the contractual status of the provider. “In-network providers” refers to healthcare service providers that the health plan has favorable contractual payment rates and “out-of-network providers” refers to healthcare service providers that the health plan has unfavorable or no contractual payment rates. To incent members to use in-network providers, health plans typically make the member cost-sharing lower than for out-of-network providers by setting different deductibles, copays, coinsurance, coverage limits and the like.

“Over the years, many attempts have been made by health plans and other managed care organizations to control medical expenditures by making adjustments to the aforementioned plan design components. Health Management Organizations were created to control medical expenditures by forcing members to utilize a very limited network of healthcare service providers with favorable contractual payment terms. High Deductible Health Plans and Consumer Driven Health Plans were created to incent members to shop around for healthcare services by forcing them to pay a high deductible before the health plan would share in the costs. However, according to National Health Expenditures Account data, these attempts to control medical expenditures have largely been unsuccessful with medical expenditures growing from 5% of the U.S. GDP in 1960 to nearly 18% of the U.S. GDP in 2019.

“Furthermore, traditional plan designs are cumbersome and difficult for members to understand. Many plan designs contain different cost-share arrangements for the different types of service (e.g., professional or facility charges) and create confusion on the amount of payment required. Often, a member will not know amount of payment required at point of service and will only find out after-the-fact via a bill from the healthcare service provider or the health plan’s explanation of benefits. Additionally, a member often has difficulty knowing what healthcare service providers are considered in-network and has to contact the health plan or healthcare service provider to verify network status.

“In view of the above, there is a need for a computer implemented method and system that obviates the deficiencies of existing plan designs, along with providing other benefits.”

In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventor’s summary information for this patent application: “The following presents a simplified summary of some embodiments of the invention in order to provide a basic understanding of the invention. This summary is not an extensive overview of the invention. It is not intended to identify key/critical elements of the invention or to delineate the scope of the invention. Its sole purpose is to present some embodiments of the invention in a simplified form as a prelude to the more detailed description that is presented later.

“Various embodiments of the present disclosure provide methods and systems for health plan design administration for healthcare services.

“An embodiment of the invention provides, among other things, a method for a member to purchase healthcare services based upon the urgency of receiving treatment. Rather than bifurcate the purchasing decision based upon in-network and out-of-network providers, a member’s purchasing decision is based upon the bifurcation of “emergency” and “planned” medical expenditure. As used herein, the term “emergency medical” refers to an event that requires immediate medical attention because of extreme bodily distress or to prevent the loss of life or permanent function. Additionally, as used herein, the term “planned medical” refers to an event that does not require immediate medical attention and can be scheduled in advance. The method includes classifying the emergency medical and planned medical expenditures based upon a predefined rule set utilizing, among other things, a list valid diagnoses and procedures.

“Another embodiment of the invention provides, among other things, a method for a member to purchase emergency medical. During times of medical distress, it is unreasonable to expect a member to make a purchasing decision based upon the typical bifurcation of in-network and out-of-network provider as the member may be requiring the most readily available provider. Preferably, the member would be allowed to see any qualified and credentialed healthcare service provider and would not be financially penalized for the selection of a healthcare service provider. The method includes a member cost-share arrangement specifically for emergency medical expenditures and may include deductibles, copays and coinsurance.

“Another embodiment of the invention provides, among other things, a method for a member to purchase planned medical expenditures. The method includes a way for the member to make an informed purchasing decision based upon cost and quality by using a marketplace with competing healthcare service providers. The “marketplace” is any mechanism that allows for comparison of healthcare services across different healthcare service providers with transparent pricing. The method includes a member cost-share arrangement specifically for planned medical expenditures and may include deductibles, copays and coinsurance. Preferably, the member cost-share would be directly correlated to the total cost of the planned medical expenditure and as the total cost of the planned medical went up, so would the member cost-share amount.

“In another embodiment, a computer implemented method is disclosed. For an emergency medical expenditure, the method includes receiving, by a processor, member information and one or more claims associated with the member from at least one healthcare service provider. Each claim is associated with one or more healthcare services availed by the member during the emergency medical event. The method includes processing, by the processor, the one or more claims for determining validity of each emergency medical claim of the one or more claims based on a predefined emergency medical rule set. The method further includes upon processing the one or more claims, facilitating, by the processor, a payment amount for the one or more claims of the at least one healthcare service provider based on the validity.

“In another embodiment, a server system is disclosed. The server system comprises a memory to store instructions and a processor to execute the stored instructions in the memory and thereby cause the server system to receive member and claim information of a member. The member information comprises at least a member identifier and one or more claims associated with the member from at least one healthcare service provider. Each claim is associated with one or more healthcare services availed by the member during the emergency medical event. The server system is further caused to process the one or more claims for determining the validity of each claim of the one or more claims based on a predefined emergency medical rule set. The server system is furthermore caused to facilitate a payment for the one or more claims of the at least one healthcare service provider based on the validity upon processing of the one or more claims.

“In another embodiment, a computer implemented method is disclosed. For a planned medical, the method includes utilizing a computer interface to present a marketplace of healthcare service providers to the member for the member to make an informed buying decision based upon quality and transparent pricing, among other things. The method includes the member prepaying for the planned medical event based upon the member’s planned medical cost-share arrangement with the health plan. The method includes generating, by the processor, a voucher for the member to avail healthcare services from one or more healthcare service providers. The method further includes facilitating, by the processor, a payment amount to one or more healthcare service providers based on the redemption of the planned medical voucher to the healthcare service provider.

“The foregoing has outlined rather broadly the more pertinent and important features of the present disclosure so that the detailed description of the invention that follows may be better understood and so that the present contribution to the art can be more fully appreciated. Additional features of the invention will be described hereinafter which form the subject of the claims of the invention. It should be appreciated by those skilled in the art that the conception and the disclosed specific methods and structures may be readily utilized as a basis for modifying or designing other structures for carrying out the same purposes of the present disclosure. It should be realized by those skilled in the art that such equivalent structures do not depart from the spirit and scope of the invention as set forth in the appended claims.

“The drawings referred to in this description are not to be understood as being drawn to scale except if specifically noted, and such drawings are only exemplary in nature.”

The claims supplied by the inventors are:

“1. A method for health plan design administration that bifurcates a member’s healthcare services purchase decision between emergency medical and planned medical events, the method comprising: if for an emergency medical event, receiving, by a processor, member information of a member, the member information comprising at least a member identifier associated with the member; receiving, by the processor, one or more claims associated with the member from at least one healthcare service provider of the one or more healthcare service providers, each claim being associated with one or more healthcare services availed by the member during the emergency medical event; processing, by the processor, the one or more claims for determining validity of each claim of the one or more claims based on a predefined emergency medical rule set; calculating, by the processor, the member responsibility of the one or more claims of the emergency medical event; and upon processing the one or more claims, facilitating, by the processor, a payment amount for the one or more claims of the at least one healthcare service provider based on the validity; if for a planned medical event, receiving, by the processor, member login information of the member to the member portal; presenting, by the processor, one or more healthcare service vouchers available for purchase by the member, each voucher representing one or more healthcare services from the one or more healthcare service providers available to the member during the planned medical event; calculating, by the processor, the member responsibility of the healthcare service voucher; processing, by the processor, member payment for the member responsibility of the one or more healthcare service vouchers; generating, by the processor, a voucher for the member to avail healthcare services from the one or more healthcare service providers for the planned medical event, the voucher comprising reimbursement information for the healthcare services availed by the member from the one or more healthcare service providers; upon redemption of voucher, facilitating, by the processor, a reimbursement payment amount for the one or more claims associated with the voucher of the one or more healthcare service providers.

“2. The method as claimed in claim 1, wherein calculating the member responsibility comprises: if for an emergency medical event, accessing, by the processor, the emergency medical cost-share information of the member; and calculating, by the processor, the member responsibility based on the emergency medical cost-share information; if for a planned medical event, accessing, by the processor, the planned medical cost-share information of the member for each voucher; and calculating, by the processor, the member responsibility voucher price based on the planned medical cost-share information.

“3. The method as claimed in claim 1, wherein processing the one or more emergency medical claims comprises: classifying, by the processor, the one or more claims as a valid claim or an invalid claim; and facilitating, by the processor, a notification for the member and the at least one healthcare service provider related to the valid or the invalid claim, the notification comprising reasons for determining the valid or the invalid claim.

“4. The method as claimed in claim 3, further comprising: upon determining the valid claim, accessing, by the processor, a contracted payment rate for payment of at least a part of the payment amount for the one or more healthcare services associated with the valid claim; and facilitating, by the processor, payment of the payment amount for the valid claim associated with the one or more healthcare service providers.

“5. The method as claimed in claim 1, wherein processing the redemption of one or more planned medical vouchers comprises: upon redemption of voucher, accessing, by the processor, a contracted payment rate for payment of at least a part of the payment amount for the one or more healthcare services associated with the voucher; and facilitating, by the processor, payment of the payment amount for the one or more claims of the one or more vouchers associated with the one or more healthcare service providers.

“6. The method as claimed in claim 1, wherein the voucher comprises one or more of: the member information; the reimbursement information; and one or more healthcare services covered by the voucher.

“7. A server system, comprising: a memory configured to store instructions; and a processor configured to execute the instructions stored in the memory and thereby cause the server system to perform: if for an emergency medical event, receiving member information of a member, the member information comprising at least a member identifier associated with the member; receiving one or more claims associated with the member from at least one healthcare service provider of one or more healthcare service providers, each claim being associated with one or more healthcare services availed by the member during the emergency medical event; processing the one or more claims for determining validity of each claim of the one or more claims based on a predefined emergency medical rule set; calculating the member responsibility of the claims of the emergency medical event; and upon processing the one or more claims, facilitating a payment amount for the one or more claims of the at least one healthcare service provider based on the validity; if for a planned medical event, receiving member login information of the member to the member portal; presenting one or more healthcare service vouchers available for purchase by the member, each voucher representing one or more healthcare services from the one or more healthcare service providers available to the member during the planned medical event; calculating the member responsibility of the healthcare service voucher; processing member payment for the member responsibility of the one or more healthcare service vouchers; generating a voucher for the member to avail healthcare services from one or more healthcare service providers for the planned medical event, the voucher comprising reimbursement information for the healthcare services availed by the member from the one or more healthcare service providers; upon redemption of voucher, facilitating a reimbursement payment amount for the one or more claims associated with the voucher of the one or more healthcare service providers.

“8. The server system as claimed in claim 7, wherein for calculating the member responsibility, the server system is further configured to perform at least: if for an emergency medical event, accessing the emergency medical cost-share information of the member; and calculating the member responsibility based on the emergency medical cost-share information; if for a planned medical event, accessing the planned medical cost-share information of the member for each voucher; and calculating the member responsibility voucher price based on the planned medical cost-share information.

“9. The server system as claimed in claim 7, wherein for processing the one or more emergency medical claims, the server system is further configured to perform at least: classifying the one or more claims as a valid claim or an invalid claim; and facilitating a notification for the member and the at least one healthcare service provider related to the valid or the invalid claim, the notification comprising reasons for determining the valid or the invalid claim.

“10. The server system as claimed in claim 9, wherein the server system is further configured to perform at least: upon determining the valid claim, accessing a contracted payment rate for payment of at least a part of the payment amount for the one or more healthcare services associated with the valid claim; and facilitating payment of the payment amount for the valid claim associated with the one or more healthcare service providers.

“11. The method as claimed in claim 7, wherein processing the redemption of one or more planned medical vouchers, the server system is further configured to perform at least: upon redemption of voucher, accessing a contracted payment rate for payment of at least a part of the payment amount for the one or more healthcare services associated with the voucher; and facilitating payment of the payment amount for the one or more claims of the one or more vouchers associated with the one or more healthcare service providers.

“12. The server system as claimed in claim 7, wherein the voucher comprises one or more of: the member information; the reimbursement information; and one or more healthcare services covered by the voucher.”

For more information, see this patent application: Niemeyer, Mark. Computer Implemented Methods And Systems For Health Plan Design Administration. U.S. Patent Application Number 20230069388, filed August 25, 2021 and posted March 2, 2023. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(20230069388)&db=US-PGPUB&type=ids

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