Patent Issued for Adjudication and claim submission for selectively redeemable bundled healthcare services (USPTO 11842374): Mdsave Shared Services Inc.

2024 JAN 03 (NewsRx) -- By a News Reporter-Staff News Editor at Health Policy and Law Daily -- A patent by the inventors Ketchel, III, Paul J. (Brentwood, TN, US), filed on August 8, 2022, was published online on December 12, 2023, according to news reporting originating from Alexandria, Virginia, by NewsRx correspondents.

Patent number 11842374 is assigned to Mdsave Shared Services Inc. (Brentwood, Tennessee, United States).

The following quote was obtained by the news editors from the background information supplied by the inventors: “Medical services are services provided to a medical patient. Some medical services may help improve or maintain a patient’s health, based on disease prevention, diagnosis, or treatment. The practice of medicine encompasses medical procedures performed for a patient, which may include both preventive care and treatment. Medical service providers include doctors, hospitals, and health insurers. A provider may offer medical services to patients by provisioning medical resources such as, for example, laboratory, imaging, treatment, or surgical facilities, to provide the services. Some medical services may require specially trained or licensed medical professionals. For example, a medical practice providing diagnosis and treatment for joint pain may provide medical services through the work of an orthopedic specialist. In some scenarios, patient access to a specialized professional or facility may be limited by cost, or availability. Some specialized medical professionals and related facilities may be scarce.

“A medical practice may also limit the medical procedures offered to patients based on the availability of specialized professionals and facilities at a given time or location as increasingly seen with the onset of the COVID-19 pandemic. For example, the services offered to a patient may be determined based on allocating surgeons to various surgical facility locations at specific times. Services supplied to patients may be limited to the allocated medical professionals and facilities, even when medical service demand exceeds supply at a given location or time. A medical practice providing many types of medical services may expend significant resources adapting the offered services to demand as cost and demand change. Some medical practices may fail to capture potential revenue lost when resources to provide medical services are underutilized relative to medical service demand.

“The price of healthcare services varies depending on specialty, procedure, and physician practice. In the United States, many patients do not have access to a simple way to shop and compare the price of common medical procedures. Due to the current managed care-based payor system in the US, the cost of treatment is often determined by managed care organizations.

“These managed care organizations have specific formularies for drugs and procedures designed specifically to patients’ individual health plans, which restrict the drugs and procedures available to patients in their plans. Patients have historically had no access to these price lists or formularies and have had very few tools to assist them in finding and comparing health care services or predetermining the cost of a procedure. Currently prospective patients who chose to compare medical costs are forced to conduct extensive, often inefficient, and time-consuming research to compare medical procedures prior to treatment.

“The rising cost of healthcare is having a dramatic effect on the U.S. healthcare system. Healthcare costs continue to outpace pace inflationary growth, provider reimbursement rates continue to fall, and the cost of patient insurance premiums are increasing. To lower monthly premium costs, many patients are choosing to purchase (and employers are choosing to offer) high deductible health plans as an alternative to traditional higher premium PPO health plans.

“These high deductible plans require patients to pay cash payments for medical services until the high deductible is satisfied, and once this deductible has been met, the insurance carrier begins to cover medical costs. As a result, many patients are seeing exponential increases in out-of-pocket expenses for medical procedures and services. In addition to more patients selecting high deductible plans, many patients cannot afford increased payments and are becoming uninsured or underinsured. As the number of patients who are uninsured, underinsured, or on high deductible plans grows, the need for a mechanism that allows patients to find discounted medical services increases and an efficient payment system.”

In addition to the background information obtained for this patent, NewsRx journalists also obtained the inventors’ summary information for this patent: “Herein presented is an apparatus and associated methods designed for healthcare claims adjudication, based on selectively redeemable bundled services technology. An exemplary implementation may be configured for receiving, from a customer, an electronic message comprising at least one healthcare claim for at least one patient, said claim comprising at least one healthcare service; determining, if a selectively redeemable bundled service purchase data record exists for the at least one of the services in the healthcare claim, wherein the selectively redeemable bundled service purchase data record comprises an individual redemption status of each individual bundled service; and upon determining whether the selectively redeemable bundled service purchase data record comprising the at least one service in the healthcare claim exists, sending to the customer the determination of whether the bundled healthcare service purchase data record exists and is available. One implementation generates a shopping cart with a bundled service for purchase and individually disburses payment to respective providers with an EDI X12 835 remittance message. A customer may submit a healthcare claim as an EDI X12 837 claim message.

“An exemplary implementation may be configured for receiving, from a customer, an indication at least one healthcare service has been redeemed from a bundled set of a plurality of healthcare services listed in a selectively redeemable bundled services purchase data record; updating the individual redemption status of the at least one healthcare service in the selectively redeemable bundled services purchase data record to indicate the at least one healthcare service has been redeemed; sending, to the customer, an electronic message comprising a request for payment for the at least one healthcare service; and upon receiving the payment in combination with the indication at least one healthcare service has been redeemed, disbursing compensation allocated from the payment to at least one provider, using the processor. One implementation may create and send X12 837 claims to payers on behalf of participant providers of the bundled services and receive response X12 835 remittance with the payments requested from the payers.

“An exemplary implementation may be configured for presenting users a selection of at least one bundled set of healthcare services provided discretely and/or individually by a plurality of respective providers, determining a bundle price for the bundled set of healthcare services, receiving payment for the user selected bundled set, generating a purchase data record hereafter interchangeably referred to as a “voucher” or “voucher data record” selectively redeemable by the user to receive each of the bundled healthcare services in the bundled set, transmitting a unique confirmation number generated for the purchase data record to track the redemption status of the purchase data record, disbursing payment allocated from the received payment to the plurality of respective providers and updating the individual redemption status of each of the plurality of services represented by the purchase data record as each of the plurality of services of the bundled set are redeemed. The bundle price may be based on the user’s health insurance deductible as well as the location and/or time at which the bundled set of services will be provided.

“The above-described and other features and advantages realized through the techniques of the present disclosure will be better appreciated and understood with reference to the following detailed description, drawings, and appended claims. Additional features and advantages are realized through the techniques of the present invention. Other embodiments and aspects of the invention are described in detail herein and are considered a part of the claimed invention.

“The detailed description explains exemplary embodiments of the present invention, together with advantages and features, by way of example with reference to the drawings, in which similar numbers refer to similar parts throughout the drawings. The flow diagrams depicted herein are just examples. There may be many variations to these diagrams, or the steps (or operations) described therein without departing from the spirit of the invention. For instance, the steps may be performed in a differing order, or steps may be added, deleted, or modified. All these variations are considered to be within the scope of the claimed invention.”

The claims supplied by the inventors are:

“1. A method comprising: receiving, from a customer, an electronic message comprising at least one 837 healthcare claim for at least one patient, the at least one 837 healthcare claim comprising at least one claimed healthcare service, using a processor; determining, if the at least one claimed healthcare service is a healthcare service existing in a data store comprising a plurality of healthcare services to be performed by a plurality of providers and grouped into at least one preexisting healthcare service offer, using the processor; and in response to determining whether the at least one claimed healthcare service is included in at least one healthcare service offer, generating an electronic health record (EHR) comprising a selectively redeemable information record identified by and with machine-readable information uniquely associated with the selectively redeemable information record, wherein, the selectively redeemable information record comprises the at least one preexisting healthcare service offer that includes the at least one claimed healthcare service and a corresponding price for the at least one preexisting healthcare service offer, further wherein, each healthcare service of the at least one preexisting healthcare service offer is individually selectively redeemable as a function of the machine-readable information, using the processor; presetting an initial individual redemption status for each healthcare service in the at least one preexisting healthcare service offer in the generated EHR to unredeemed, using the processor; and providing the customer with access to the generated EHR, using the processor.

“2. The method of claim 1, wherein the method further comprises receiving an electronic message comprising a payment for at least one healthcare service of a bundled set of a plurality of selectively redeemable healthcare services to be provided by a plurality of respective providers, wherein the payment for the at least one healthcare service is pre-paid in an amount determined as a function of a bundle price based on a location at which at least one selectively redeemable healthcare service will be provided, using the processor.

“3. The method of claim 2, wherein the method further comprises in response to receiving the electronic message comprising the payment, generating an electronic health record (EHR) comprising a selectively redeemable information record identified by and with a unique confirmation number; presetting an initial individual redemption status in the selectively redeemable information record for each selectively redeemable healthcare service of the bundled set of healthcare services as purchased and unredeemed, and providing user access to the information record to receive each selectively redeemable healthcare service of the plurality of healthcare services, using the processor.

“4. The method of claim 3, wherein the method further comprises storing the EHR in a memory operably coupled with the processor; and sending the EHR to at least one provider of the plurality of respective providers, using the processor.

“5. The method of claim 3, wherein the method further comprises sending the unique confirmation number to the patient, using the processor.

“6. The method of claim 1, wherein the electronic message comprising the healthcare claim further comprises a claim services or patient identification, and wherein the method further comprises: determining, if a selectively redeemable information record exists using the claim services or patient identification, using the processor.

“7. The method of claim 1, wherein the method further comprises receiving an EDI X12 message, using the processor.

“8. The method of claim 1, wherein the method further comprises sending an EDI X12 message, using the processor.

“9. The method of claim 1, wherein the method further comprises in response to receiving an electronic message comprising an eligibility check, determining, if a selectively redeemable information record associated with the patient exists, using the processor.

“10. The method of claim 9, wherein the eligibility check is a 278 eligibility check.

“11. The method of claim 1, wherein the method further comprises receiving a 278 eligibility check result indicating the at least one patient has current benefits to cover the at least one service in the 837 healthcare claim.

“12. The method of claim 1, wherein the method further comprises generating a shopping cart with the at least one healthcare service in the healthcare claim that is available, using the processor.

“13. The method of claim 12, wherein the method further comprises presenting the shopping cart to the customer, using the processor.

“14. The method of claim 13, wherein presenting the shopping cart to the customer further comprises sending the customer a link to the shopping cart, using the processor.

“15. The method of claim 1, wherein sending to the customer the determination of whether the selectively redeemable information record exists and is available for purchase or redemption, using the processor.

“16. The method of claim 1, wherein the method further comprises upon determining the selectively redeemable information record associated with the patient does not exist for at least one healthcare service of the plurality of healthcare services in the healthcare claim, generating a shopping cart with the at least one healthcare service for which a selectively redeemable information record does not exist, using the processor.

“17. The method of claim 16, wherein the method further comprises receiving payment for the shopping cart with the at least one healthcare service, using the processor.

“18. The method of claim 16, wherein the method further comprises presenting the shopping cart to the customer, using the processor.

“19. The method of claim 18, wherein presenting the shopping cart to the customer further comprises sending the customer a link to the shopping cart, using the processor.

“20. The method of claim 1, wherein the method further comprises determining the individual redemption status of at least one healthcare service of a plurality of healthcare services encoded by a selectively redeemable information record, and upon a determination the redemption status of the at least one healthcare service indicates the healthcare service is redeemable, sending an electronic message to the customer comprising an indication the at least one healthcare service is redeemable, using the processor.

“21. The method of claim 1, wherein the method further comprises in response to receiving an electronic message comprising an indication at least one healthcare service of a plurality of healthcare services encoded by a selectively redeemable information record has been redeemed, sending to the customer an electronic message requesting payment for the at least one healthcare service, using the processor.

“22. The method of claim 21, wherein the method further comprises receiving the requested payment for the at least one healthcare service, using the processor.

“23. The method of claim 22, wherein the method further comprises disbursing compensation allocated from the received payment to at least one provider, using the processor.

“24. The method of claim 23, wherein the method further comprises sending an 835 remittance advice to the at least one provider, using the processor.

“25. The method of claim 23, wherein the method further comprises reporting an updated status of the healthcare claim to indicate the at least one healthcare service has been paid, using the processor.

“26. The method of claim 1, wherein the method further comprises reporting to an insurer an amount paid for the at least one healthcare service, using the processor.

“27. The method of claim 1, wherein the method further comprises reporting to the patient’s insurance deductible an amount paid out of pocket by the patient for the at least one healthcare service, using the processor.

“28. The method of claim 1, wherein the customer is a provider.

“29. The method of claim 1, wherein the customer is one of: an insurer, an employer, a financier, a third-party, or a clearing house.

“30. The method of claim 1, wherein the customer is the patient.”

URL and more information on this patent, see: Ketchel, III, Paul J. Adjudication and claim submission for selectively redeemable bundled healthcare services. U.S. Patent Number 11842374, filed August 8, 2022, and published online on December 12, 2023. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(11842374)&db=USPAT&type=ids

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