Patent Application Titled “Methods, Systems And Computer Program Products For Making Payment Recommendations For Health Care Claim Lines Having Date Spans” Published Online (USPTO 20230316406): Patent Application
2023 OCT 23 (NewsRx) -- By a
No assignee for this patent application has been made.
Reporters obtained the following quote from the background information supplied by the inventors: “Health care services are delivered to patients through health care providers, e.g., one or more medical practitioners. Payment for these services is usually made by one or more payors, which may include the patient and another entity, such as an insurance company. Both private companies and public organizations, such as the Medicare and Medicaid programs run by the federal government, and public employee programs run by the federal government or states, may act as payors. Payors may be penalized for improperly denying payment for health care service claims, but may also be harmed financially for approving payment for claims that cannot be justified. To improve the accuracy in determining which claims to pay, which claims to pay in part, and which claims to deny, payors may use an auditing system that provides recommendations on the payment process. The auditing system may be designed with various packages of rules that can be applied to the claims to make the recommendations on payment.
“A health care service claim may include both header and line information. The header may be information that applies to the entire claim, e.g., patient details (name, date of birth, address, etc.). The line information may identify the various services, products, fees, expenses, and/or other items for which payment is sought and may be referred to as line item(s). A payor, such as an insurance company operating in the health care field, may make use of a claims auditing system to assist them in determining whether to pay and how much to pay for the various lines listed in claims submitted for payment.
“Unfortunately, conventional auditing systems may not have the ability to accurately review and process claims for services rendered over a period of time (e.g., days, weeks, months, etc.), referred to as a “date span”. Three options are typically available to conventional auditing systems when reviewing and processing claim lines having a date span: 1) ignore the claim line and perform no review; 2) use the beginning date of service in a claim line to process the claim line; or 3) use the ending date of service in a claim line to process the claim line. However, selection of an individual date option can result in incorrect or no auditing of a claim line and may result in a loss of potential editing opportunities as the entire date span is not evaluated accurately.”
In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventors’ summary information for this patent application: “Embodiments of the present inventive concept provide enhanced date span frequency functionality to accurately address claim lines submitted with a date span by evaluating both a line’s beginning date of service (referred to as “Line_DosFrom”) and the line’s ending date of service (referred to as “Line_DosTo”) and auditing the line accordingly. Date spans may include days, weeks, months, etc. Embodiments of the present inventive concept provide the ability to evaluate claim lines submitted with a date span and to recalculate the maximum frequency allowed for health care services identified in submitted claim lines.
“According to some embodiments of the inventive concept, a method comprises receiving a first claim line that identifies a first time span and a first quantity of a health care service provided to a patient during the first time span; determining whether the quantity of the health care service provided to the patient during the first time span exceeds a maximum amount for a predefined time period; determining whether the first time span exceeds the predefined time period; extending the predefined time period past an ending date of the first time span in response to determining whether the first time span exceeds the predefined time period and that the quantity of service provided in the first claim line exceeds the maximum amount for the predefined time period; and generating a payment recommendation for the first claim line in response to determining whether the quantity of the health care service provided to the patient exceeds the maximum amount for the predefined time period and/or in response to determining whether the quantity of the health care service provided in the first time span exceeds a maximum amount for the extended predefined time period. The sender may be a payor and/or provider of the health care service. The predefined time period may be one of the following: one or more days, one or more weeks, one or more months, one or more years. The payment recommendation may be a recommendation to pay or not pay the first claim line.
“In some embodiments, the method further comprises receiving a second claim line that identifies a second time span and a second quantity of the health care service provided to the patient during the second time span; determining whether a beginning date of the second time span is within the predefined time period; extending the predefined time period past an ending date of the second time span; generating a payment recommendation for the second claim line in response to determining whether the quantity of the health care service provided to the patient in the first claim line and the quantity of the health care service provided to the patient in the second claim line exceeds a maximum amount for the extended predefined time period, wherein the payment recommendation is a recommendation to pay or not pay the second claim line; and communicating the payment recommendation for the second claim line to a sender of the second claim line.
“In some embodiments, the method further comprises generating a third claim line in response to determining that the quantity of the health care service provided in the first claim line and the quantity of the health care service provided in the second claim line exceeds the maximum amount for the extended predefined time period, wherein the third claim line contains a quantity of the health care service provided that is less than the quantity of the health care service provided in the second claim line; generating a recommendation not to pay the second claim line for a quantity of the health care service in the second claim line that exceeds the maximum amount for the predefined time period and a recommendation to pay the third claim line for a quantity of the health care service in the third claim line that does not exceed the maximum amount for the predefined time period; and communicating the payment recommendation for the second claim line and the third claim line to a sender of the first line and the second line.
“According to some embodiments of the inventive concept, a system comprises a processor and a memory coupled to the processor and comprising computer readable program code embodied in the memory that is executable by the processor to perform operations comprising: receiving a first claim line that identifies a first time span and a first quantity of a health care service provided to a patient during the first time span; determining whether the quantity of the health care service provided to the patient during the first time span exceeds a maximum amount for a predefined time period; determining whether the first time span exceeds the predefined time period; extending the predefined time period past an ending date of the first time span in response to determining whether the first time span exceeds the predefined time period and that the quantity of service provided in the first claim line exceeds the maximum amount for the predefined time period; and generating a payment recommendation for the first claim line in response to determining whether the quantity of the health care service provided to the patient exceeds the maximum amount for the predefined time period and/or in response to determining whether the quantity of the health care service provided in the first time span exceeds a maximum amount for the extended predefined time period.
“In some embodiments, the operations further comprise receiving a second claim line that identifies a second time span and a second quantity of the health care service provided to the patient during the second time span; determining whether a beginning date of the second time span is within the predefined time period; extending the predefined time period past an ending date of the second time span; generating a payment recommendation for the second claim line in response to determining whether the quantity of the health care service provided to the patient in the first claim line and the quantity of the health care service provided to the patient in the second claim line exceeds a maximum amount for the extended predefined time period, wherein the payment recommendation is a recommendation to pay or not pay the second claim line; and communicating the payment recommendation for the second claim line to a sender of the second claim line.
“In some embodiments, the operations further comprise generating a third claim line in response to determining that the quantity of the health care service provided in the first claim line and the quantity of the health care service provided in the second claim line exceeds the maximum amount for the extended predefined time period, wherein the third claim line contains a quantity of the health care service provided that is less than the quantity of the health care service provided in the second claim line; generating a recommendation not to pay the second claim line for a quantity of the health care service in the second claim line that exceeds the maximum amount for the predefined time period and a recommendation to pay the third claim line for a quantity of the health care service in the third claim line that does not exceed the maximum amount for the predefined time period; and communicating the payment recommendation for the second claim line and the third claim line to the sender.
“According to some embodiments of the inventive concept, a computer program product, comprises a non-transitory computer readable storage medium comprising computer readable program code embodied in the medium that is executable by a processor to perform operations comprising receiving a first claim line that identifies a first time span and a first quantity of a health care service provided to a patient during the first time span; determining whether the quantity of the health care service provided to the patient during the first time span exceeds a maximum amount for a predefined time period; determining whether the first time span exceeds the predefined time period; extending the predefined time period past an ending date of the first time span in response to determining whether the first time span exceeds the predefined time period and that the quantity of service provided in the first claim line exceeds the maximum amount for the predefined time period; and generating a payment recommendation for the first claim line in response to determining whether the quantity of the health care service provided to the patient exceeds the maximum amount for the predefined time period and/or in response to determining whether the quantity of the health care service provided in the first time span exceeds a maximum amount for the extended predefined time period.
“In some embodiments, the operations further comprise receiving a second claim line that identifies a second time span and a second quantity of the health care service provided to the patient during the second time span; determining whether a beginning date of the second time span is within the predefined time period; extending the predefined time period past an ending date of the second time span; generating a payment recommendation for the second claim line in response to determining whether the quantity of the health care service provided to the patient in the first claim line and the quantity of the health care service provided to the patient in the second claim line exceeds a maximum amount for the extended predefined time period, wherein the payment recommendation is a recommendation to pay or not pay the second claim line; and communicating the payment recommendation for the second claim line to a sender of the second claim line.”
There is additional summary information. Please visit full patent to read further.”
The claims supplied by the inventors are:
“1. A method, comprising: receiving a first claim line that identifies a first time span and a first quantity of a health care service provided to a patient during the first time span; determining whether the quantity of the health care service provided to the patient during the first time span exceeds a maximum amount for a predefined time period; determining whether the first time span exceeds the predefined time period; extending the predefined time period past an ending date of the first time span in response to determining that the first time span exceeds the predefined time period and that the quantity of service provided in the first claim line exceeds the maximum amount for the predefined time period; and generating a payment recommendation for the first claim line in response to determining whether the quantity of the health care service provided to the patient exceeds the maximum amount for the predefined time period and/or in response to determining whether the quantity of the health care service provided in the first time span exceeds a maximum amount for the extended predefined time period.
“2. The method of claim 1, further comprising communicating the payment recommendation for the first claim line to a sender of the first claim line.
“3. The method of claim 2, wherein the sender is a payor and/or provider of the health care service.
“4. The method of claim 1, wherein the predefined time period is one of the following: one or more days, one or more weeks, one or more months, one or more years.
“5. The method of claim 1, wherein the payment recommendation is a recommendation to pay or not pay the first claim line.
“6. The method of claim 1, wherein the maximum amount for the extended predefined time period is greater than the maximum amount for the predefined time period.
“7. The method of claim 1, further comprising: receiving a second claim line that identifies a second time span and a second quantity of the health care service provided to the patient during the second time span; determining whether a beginning date of the second time span is within the predefined time period; extending the predefined time period past an ending date of the second time span; and generating a payment recommendation for the second claim line in response to determining whether the quantity of the health care service provided to the patient in the first claim line and the quantity of the health care service provided to the patient in the second claim line exceeds a maximum amount for the extended predefined time period, wherein the payment recommendation is a recommendation to pay or not pay the second claim line.
“8. The method of claim 7, further comprising communicating the payment recommendation for the second claim line to a sender of the second claim line.
“9. The method of claim 7, further comprising: generating a third claim line in response to determining that the quantity of the health care service provided in the first claim line and the quantity of the health care service provided in the second claim line exceeds the maximum amount for the extended predefined time period, wherein the third claim line contains a quantity of the health care service provided that is less than the quantity of the health care service provided in the second claim line; and generating a recommendation not to pay the second claim line for a quantity of the health care service in the second claim line that exceeds the maximum amount for the predefined time period and a recommendation to pay the third claim line for a quantity of the health care service in the third claim line that does not exceed the maximum amount for the predefined time period.
“10. The method of claim 9, further comprising communicating the payment recommendation for the second claim line and the third claim line to a sender of the first line and the second line.
“11. A system, comprising: a processor; and a memory coupled to the processor and comprising computer readable program code embodied in the memory that is executable by the processor to perform operations comprising: receiving a first claim line that identifies a first time span and a first quantity of a health care service provided to a patient during the first time span; determining whether the quantity of the health care service provided to the patient during the first time span exceeds a maximum amount for a predefined time period; determining whether the first time span exceeds the predefined time period; extending the predefined time period past an ending date of the first time span in response to determining that the first time span exceeds the predefined time period and that the quantity of service provided in the first claim line exceeds the maximum amount for the predefined time period; generating a payment recommendation for the first claim line in response to determining whether the quantity of the health care service provided to the patient exceeds the maximum amount for the predefined time period and/or in response to determining whether the quantity of the health care service provided in the first time span exceeds a maximum amount for the extended predefined time period; and communicating the payment recommendation for the first claim line to a sender of the first claim line.
“12. The system of claim 11, the operations further comprising: receiving a second claim line that identifies a second time span and a second quantity of the health care service provided to the patient during the second time span; determining whether a beginning date of the second time span is within the predefined time period; extending the predefined time period past an ending date of the second time span; generating a payment recommendation for the second claim line in response to determining whether the quantity of the health care service provided to the patient in the first claim line and the quantity of the health care service provided to the patient in the second claim line exceeds a maximum amount for the extended predefined time period, wherein the payment recommendation is a recommendation to pay or not pay the second claim line; and communicating the payment recommendation for the second claim line to a sender of the second claim line.
“13. The system of claim 12, the operations further comprising: generating a third claim line in response to determining that the quantity of the health care service provided in the first claim line and the quantity of the health care service provided in the second claim line exceeds the maximum amount for the extended predefined time period, wherein the third claim line contains a quantity of the health care service provided that is less than the quantity of the health care service provided in the second claim line; generating a recommendation not to pay the second claim line for a quantity of the health care service in the second claim line that exceeds the maximum amount for the predefined time period and a recommendation to pay the third claim line for a quantity of the health care service in the third claim line that does not exceed the maximum amount for the predefined time period; and communicating the payment recommendation for the second claim line and the third claim line to the sender.
“14. The system of claim 12, wherein the sender is a pay or and/or provider of the health care service.
“15. The system of claim 12, wherein the predefined time period is one of the following: one or more days, one or more weeks, one or more months, one or more years.
“16. A computer program product, comprising: a non-transitory computer readable storage medium comprising computer readable program code embodied in the medium that is executable by a processor to perform operations comprising: receiving a first claim line that identifies a first time span and a first quantity of a health care service provided to a patient during the first time span; determining whether the quantity of the health care service provided to the patient during the first time span exceeds a maximum amount for a predefined time period; determining whether the first time span exceeds the predefined time period; extending the predefined time period past an ending date of the first time span in response to determining that the first time span exceeds the predefined time period and that the quantity of service provided in the first claim line exceeds the maximum amount for the predefined time period; and generating a payment recommendation for the first claim line in response to determining whether the quantity of the health care service provided to the patient exceeds the maximum amount for the predefined time period and/or in response to determining whether the quantity of the health care service provided in the first time span exceeds a maximum amount for the extended predefined time period.
“17. The computer program product of claim 16, the operations further comprising: receiving a second claim line that identifies a second time span and a second quantity of the health care service provided to the patient during the second time span; determining whether a beginning date of the second time span is within the predefined time period; extending the predefined time period past an ending date of the second time span; generating a payment recommendation for the second claim line in response to determining whether the quantity of the health care service provided to the patient in the first claim line and the quantity of the health care service provided to the patient in the second claim line exceeds a maximum amount for the extended predefined time period, wherein the payment recommendation is a recommendation to pay or not pay the second claim line; and communicating the payment recommendation for the second claim line to a sender of the second claim line.”
There are additional claims. Please visit full patent to read further.
For more information, see this patent application: ATLURI, Rama; BEHM, Jennifer; BUKAREVA, Elena; CANALES, Julissa; KRISHNAKUMAR, Sasidharan; LICHVAR, Daniel;
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