Patent Application Titled “Recording Medium Having Improved Program For Forming A Healthcare Network” Published Online (USPTO 20230105798): USA Managed Care Organization

2023 APR 26 (NewsRx) -- By a News Reporter-Staff News Editor at Health Policy and Law Daily -- According to news reporting originating from Washington, D.C., by NewsRx journalists, a patent application by the inventors Berry, JR., Charles E. (Glendale, AZ, US); Bogle, George E. (Austin, TX, US); Price, Tyler J. (Phoenix, AZ, US); Smith, Donna J. (Austin, TX, US), filed on October 4, 2022, was made available online on April 6, 2023.

The assignee for this patent application is USA Managed Care Organization (Austin, Texas, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “In the United States, Medicare is administered by the government as a social insurance program. Medicare provides health insurance to citizens age sixty-five and older, as well as disabled individuals and those who meet other criteria. Medicare includes hospital insurance (“Part A”), which covers costs associated with hospital stays, use of skilled nursing facilities, hospice or home healthcare, and other similar expenses. Medicare also includes medical insurance (“Part B”), which covers most doctors’ services, clinical and laboratory costs, home healthcare, outpatient services, and similar costs. While Medicare can help covered individuals avoid catastrophic expenses, some Medicare plans only cover a portion (typically 80%) of expenses related to certain procedures, while the beneficiary is responsible for the remainder of the associated costs. Additionally, Medicare Part A includes a deductible amount (for example, $1,184 in 2013), which must be paid by the beneficiary. Further, any hospital stays that exceed sixty days in length incur a daily cost that must be paid by the beneficiary. And, any hospital stays that exceed ninety days require a greater daily cost to be paid and consume a limited number of “lifetime reserve days” allotted to each beneficiary. Once these lifetime reserve days are used, the full cost of each successive day of a hospital stay must be paid by the beneficiary. Similar policies, such as coinsurance for use of skilled nursing facilities, apply to other types of medical facilities.

“Even though Medicare covers the costs associated with a large portion of a beneficiary’s healthcare transactions, beneficiaries remain burdened with considerable expenses not covered by Medicare, which can constitute a significant hardship for senior citizens and disabled individuals. As such, many private insurance companies offer supplemental insurance policies for Medicare beneficiaries, colloquially termed “Medigap” policies. While the premiums assessed by insurance providers for such policies are normally very costly, most Medicare supplemental insurance policies cover a patient’s Medicare Part A deductible, as well as any portion of a healthcare expense not covered by Medicare. Many supplemental insurance policies also cover expenses associated with hospital stays that exceed the length covered by Medicare. Many beneficiaries are unable to pay the costs associated with medical expenses not covered by Medicare, and hospitals are forced to write off these costs as uncollectable had debts. As such, hospitals and other medical facilities strongly prefer treating patients covered by Medicare supplemental insurance policies due to the fact that revenue supplied by an insurance provider is not subject to the risk of becoming uncollectable in the same manner as an amount owed directly by a patient.

“A need therefore exists for processes that can facilitate reduced premium expenses for beneficiaries of Medicare supplemental insurance policies, enabling a larger number of patients to obtain coverage by such policies. A need also exists for processes that increase hospital revenues, decrease transactional costs for hospitals and insurance providers, and reduce the number of patients not covered by a Medicare supplemental insurance policy. A need further exists for computer programs that can more efficiently and accurately categorize healthcare claims into in-network claims and out-of-network claims, in order to determine whether the non-network hospitals that have submitted healthcare claims may be good candidates for joining a centralized network.

“Embodiments usable within the scope of the present disclosure meet these needs.”

In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventors’ summary information for this patent application: “Example embodiments described herein relate, generally, to computer programs (stored on non-transitory computer readable recording mediums), systems and methods for reducing costs of healthcare transactions, including transactions between healthcare facilities and insurance providers that relate to Medicare claims, while the systems and method themselves are not part of Medicare or the Medicare payment process. A plurality of medical facilities (e.g., general or specialty hospitals, skilled nursing facilities, home healthcare providers, hospices, bariatric surgery facilities, chemical dependency facilities, long-term care facilities, physical rehabilitation centers, psychiatric facilities, residential treatment centers, sub-acute facilities, medical practitioners and groups thereof, and/or similar facilities) may be contracted to waive (e.g., subtract) at least a portion of an inpatient deductible for a group of insured patients. Concurrently, a plurality of insurance providers may be contracted to provide a premium credit to each insured patient that conducts an inpatient healthcare transaction with a contracted medical facility.

“As one example, contracted hospitals may agree to waive all or a portion of the Medicare Part A deductible for all Medicare patients who have Medicare supplemental insurance coverage that elect to use their facility. Concurrently, a provider of a Medicare supplemental insurance policy may agree to provide a patient with a $100 premium credit when the patient chooses to use a hospital that has agreed to waive all or a portion of the Medicare Part A deductible. Medicare beneficiaries, who also have Medicare supplemental insurance coverage, are thereby provided with an incentive to use contracted hospitals to receive the premium credit while remaining free to use other Medicare-participating facilities as well. Thus, Medicare beneficiaries, who also have Medicare supplemental insurance coverage, avoid payment of the Medicare Part A deductible, which is a covered benefit through their contracted insurance provider, and may also receive reduced premium expenses through the premium credit. Additionally, Medicare beneficiaries, who also have Medicare supplemental insurance coverage, whether they use a contracted hospital or not, benefit from the savings resulting from the Part A deductible waivers because the contracted insurance providers use these savings to reduce the severity of premium rate increases for all policyholders.

“While hospitals and other medical facilities would incur costs associated with waiving all or a portion of a deductible, medical facilities would see increased revenue through additional patients that would be incentivized to select a contracted medical facility. Additionally, incentivized patients that are covered by contracted insurance policies would provide a reliable source of revenue for medical facilities, reducing the number and the impact of had debts and uncollectable patient balances. Demographic and/or financial data may be analyzed (e.g., via a computer-based analysis) to identify medical facilities suitable for contracting, and/or to determine whether contracting to waive a deductible amount would be profitable for a medical facility. While contracted insurance providers would incur the cost associated with providing a premium credit to beneficiaries, insurance providers would also see increased revenue through additional enrolled beneficiaries incentivized by such premium credits, and cost savings associated with the waiver of all or a portion of the deductible amount by contracted medical facilities. Additionally, the increased revenue and reduced risk experienced by medical facilities can enable claims submitted to insurers to be re-priced, further reducing the costs borne by insurance providers. Similarly, the waiver of a deductible amount by contracted medical facilities can enable claims to be re-priced by insurers in a manner more profitable to medical facilities.

“Thus, embodiments of the present disclosure provide for the management of a Medicare supplemental insurance network in which a healthcare provider waives all or a portion of the Part A deductible owed for services rendered, as part of its contractual obligation with the Medicare supplemental insurance network. In turn, a Medicare supplemental insurance provider receives a claim from the healthcare provider, re-prices the claim based on the Part A deductible waiver, and then issues payment to the healthcare provider based on the re-priced claim. The Medicare supplemental insurance provider can then issue a report to the Medicare supplemental insurance network for claims incurred, and may also issue a fee payment to the Medicare supplemental insurance network, which can be based on the amount saved and/or an amount of increased revenue experienced.

“In an embodiment, a non-transitory computer readable recording medium stores a program to be executed on a computer. The program causes the computer to execute steps for forming a network for healthcare, comprising: electronically receiving items of information about a plurality of medical facilities, each item of information including at least a name and/or an address belonging to one of the plurality of medical facilities; storing the items of information into a first database; determining whether one of the items of information stored in the first database is from an in-network medical facility found within the network, or is from an out-of-network medical facility that is outside of the network, wherein the determining comprises: analyzing words in the name and/or the address to determine if at least one of the words matches a word of a network name and/or a network address of one of the in-network medical facilities stored in a second database, wherein a match is found under a condition in which a predetermined number of letters in a word of a predetermined length of characters in the item of information is the same as letters in a word having a same length of characters of an in-network medical facility; resolving that the item of information is from an in-network medical facility when a match is found, and that the item of information is from an out-of-network medical facility when a match is not found; and adding to the network the out-of-network medical facility.

“In an embodiment, the condition is met when at least one of the following occurs: all of the characters in a one or two character word in the name and/or the address in the item of information are the same as the characters in a one or two character word of an in-network medical facility; at least all but one of the characters in a three to five character word in the name and/or the address in the item of information are the same as the characters in a three to five character word of an in-network medical facility; and at least all but two of the characters in a six or greater character word in the name and/or the address in the item of information are the same as the characters in a six or greater character word of an in-network medical facility.

“In an embodiment, the steps further comprise providing a user override that allows a user to store the item of information in the second database as an in-network medical facility.

“In an embodiment, wherein the user override is provided when no match is found.

“In an embodiment, the user override is provided before the analyzing.

“In an embodiment, the steps further comprise building the second database with the items of information stored by the user override so that the analyzing increases in accuracy over time.

“In an embodiment, the steps further comprise: when a match is found, displaying the name and/or the address of the in-network medical facility with the matched word highlighted.

“In an embodiment, the steps further comprise: when more than one match is found, displaying the names and/or the addresses of the in-network medical facilities with the matching words in a hierarchical order according to a number of highlight words in each of the names and/or the addresses of the in-network medical facilities.

“In an embodiment, the steps further comprise: when a match is found, mapping a previously generated contract to the in-network medical facility having the item of information, the mapping based on at least one of: an identification number associated with the in-network medical facility, a date of service associated with the in-network medical facility, and state within which the in-network medical facility resides.

“In an embodiment, the out-of-network medical facility is added to the network when it is determined that the out-of-network medical facility generates a revenue “X” that is a positive number, wherein “X” is determined by the equation: X=[(R+S)-(D*A)]/N wherein “X” represents a monetary amount, “R” represents revenue due to increased patient admissions, “S” represents a monetary value of a payment from an insurance carrier, “D” represents a monetary amount of a deductible payment that is waived, “A” represents an adjusted revenue amount, and N represents a total number of new patient admissions, and wherein “R” is calculated by a computer processor based on the computer processor’s evaluation of: demographic data that predicts the number of medical facilities needed, financial data of the plurality of medical facilities to determine which revenue stream comes from each type of insurance accepted by the medical facilities, admission and discharge data to predict the number of insured patients within a geographic area, and physician data to apply a grade to physicians having admitting privileges.”

There is additional summary information. Please visit full patent to read further.”

The claims supplied by the inventors are:

“1. A non-transitory computer readable recording medium storing a program to be executed on a computer, the program causing the computer to execute steps for forming a network for healthcare, comprising: electronically receiving items of information about a plurality of medical facilities, each item of information including at least a name and/or an address belonging to one of the plurality of medical facilities; storing the items of information into a first database; determining whether one of the items of information stored in the first database is from an in-network medical facility found within the network, or is from an out-of-network medical facility that is outside of the network, wherein the determining comprises: analyzing words in the name and/or the address to determine if at least one of the words matches a word of a network name and/or a network address of one of the in-network medical facilities stored in a second database, wherein a match is found under a condition in which a predetermined number of letters in a word of a predetermined length of characters in the item of information is the same as letters in a word having a same length of characters of an in-network medical facility; resolving that the item of information is from an in-network medical facility when a match is found, and that the item of information is from an out-of-network medical facility when a match is not found; and adding to the network the out-of-network medical facility.

“2. The non-transitory computer readable recording medium of claim 1, wherein the condition is met when at least one of the following occurs: all of the characters in a one or two character word in the name and/or the address in the item of information are the same as the characters in a one or two character word in the name and/or the address of an in-network medical facility; at least all but one of the characters in a three to five character word in the name and/or the address in the item of information are the same as the characters in a three to five character word of an in-network medical facility; and at least all but two of the characters in a six or greater character word in the name and/or the address in the item of information are the same as the characters in a six or greater character word in the name and/or the address of an in-network medical facility.

“3. The non-transitory computer readable recording medium of claim 1, the further comprising: providing a user override that allows a user to store the item of information in the second database as an in-network medical facility.

“4. The non-transitory computer readable recording medium of claim 3, wherein the user override is provided when no match is found.

“5. The non-transitory computer readable recording medium of claim 3, wherein the user override is provided before the analyzing.

“6. The non-transitory computer readable recording medium of claim 3, further comprising: building the second database with the items of information stored by the user override so that the analyzing increases in accuracy over time.

“7. The non-transitory computer readable recording medium of claim 1, the further comprising: when a match is found, displaying the name and/or the address of the in-network medical facility with the matched word highlighted.

“8. The non-transitory computer readable recording medium of claim 7, the further comprising: when more than one match is found, displaying the names and/or the addresses of the in-network medical facilities with the matching words in a hierarchical order according to a number of highlight words in each of the names and/or the addresses of the in-network medical facilities.

“9. The non-transitory computer readable recording medium of claim 1, the further comprising: when a match is found, mapping a previously generated contract to the in-network medical facility having the item of information, the mapping based on at least one of: an identification number associated with the in-network medical facility, a date of service associated with the in-network medical facility, and state within which the in-network medical facility resides.

“10. The non-transitory computer readable recording medium of claim I. wherein the out-of-network medical facility is added to the network when it is determined that the out-of-network medical facility generates a revenue “X” that is a positive number, wherein “X” is determined by the equation:

“ X=[(R+S)-(D*A)]/N wherein “X” represents a monetary amount, “R” represents revenue due to increased patient admissions, “S” represents a monetary value of a payment from an insurance carrier, “D” represents a monetary amount of a deductible payment that is waived, “A” represents an adjusted revenue amount, and N represents a total number of new patient admissions, and wherein “R” is calculated by a computer processor based on the computer processor’s evaluation of: demographic data that predicts the number of medical facilities needed, financial data of the plurality of medical facilities to determine which revenue stream comes from each type of insurance accepted by the medical facilities, admission and discharge data to predict the number of insured patients within a geographic area, and physician data to apply a grade to physicians having admitting privileges.

“11. The non-transitory computer readable recording medium of claim 10, further comprising: waiving at least a portion of a deductible owed to the out-of-network medical facility that is added to the network, upon performance of a healthcare transaction by a member of a group of insured patients; providing a premium credit to the member of the group of insured patients upon performance of the healthcare transaction with the out-of-network medical facility added to the network; receiving a claim from the each respective member of the plurality of insurance providers; re-pricing the claim by subtracting the at least a portion of the deductible; and issuing the premium credit to the member of the group of the insured patients associated with the claim.

“12. The non-transitory computer readable recording medium of claim 11, wherein the plurality of insurance providers comprises Medicare supplemental insurance providers, and the deductible comprises a Medicare Part A deductible.

“13. The non-transitory computer readable recording medium of claim I, wherein the plurality of medical facilities comprises at least one of a hospital, skilled nursing facility, home healthcare provider, hospice, bariatric surgery facility, chemical dependency center, long-term care facility, physical rehabilitation center, psychiatric facility, residential treatment center, sub-acute facility, medical practitioner, and group of medical practitioners.

“14. A non-transitory computer readable recording medium storing a program to be executed on a computer, the program causing the computer to execute steps for forming a network for healthcare, comprising: electronically receiving items of information about a plurality of medical facilities, each item of information including at least a name and/or an address belonging to one of the plurality of medical facilities; storing the items of information into a first database; determining whether one of the items of information stored in the first database is from an in-network medical facility found within the network, or is from an out-of-network medical facility that is outside of the network, wherein the determining comprises: analyzing words in the name and/or the address to determine if at least one of the words matches a word of a network name and/or a network address of one of the in-network medical facilities stored in a second database, wherein a match is found when at least one of the following conditions is met in the analyzing: at least all but one of the characters in a three to five character word in the name and/or the address in the item of information are the same as the characters in a three to five character word in the name and/or the address of a network medical facility, and at least all but two of the characters in a six or greater character word in the name and/or the address in the item of information are the same as the characters in a six or greater character word in the name and/or the address of a network medical facility; resolving that the item of information is from an in-network medical facility when a match is found, and that the item of information is from an out-of-network medical facility when a match is not found; and adding to the network the out-of-network medical facility.

“15. The non-transitory computer readable recording medium of claim 14, the further comprising: providing a user override that allows a user to store the item of information in the second database as an in-network medical facility.

“16. The non-transitory computer readable recording medium of claim 15, wherein the user override is provided when no match is found.

“17. The non-transitory computer readable recording medium of claim 15, wherein the user override is provided before the analyzing.

“18. The non-transitory computer readable recording medium of claim 15, further comprising: building the second database with the items of information stored by the user override so that the analyzing increases in accuracy over time.

“19. The non-transitory computer readable recording medium of claim 14, the further comprising: when a match is found, displaying the name and/or the address of the in-network medical facility with the matched word highlighted.”

There are additional claims. Please visit full patent to read further.

For more information, see this patent application: Berry, JR., Charles E.; Bogle, George E.; Price, Tyler J.; Smith, Donna J. Recording Medium Having Improved Program For Forming A Healthcare Network. U.S. Patent Application Number 20230105798, filed October 4, 2022 and posted April 6, 2023. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(20230105798)&db=US-PGPUB&type=ids

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