Patent Issued for Centralized Accumulator Systems And Methods (USPTO 10,042,982)

By a News Reporter-Staff News Editor at Managed Care Weekly Digest -- According to news reporting originating from Alexandria, Virginia, by NewsRx journalists, a patent by the inventor Zielinski, Thomas E. (New Vernon, NJ), filed on May 19, 2014, was published online on August 20, 2018 (see also UnitedHealth Group Incorporated).

The assignee for this patent, patent number 10,042,982, is UnitedHealth Group Incorporated (Minnetonka, Minnesota, United States).

Reporters obtained the following quote from the background information supplied by the inventors: "Many health insurance plans provide shared deductible and out-of-pocket limits that cover different types of benefits. For instance, a medical plan may share deductible and out-of-pocket expenses with the pharmacy and behavioral benefit plans. All of a member's medical, pharmacy and behavioral claims would be applied against one deductible plan limit and one out-of-pocket limit, instead of three separate sets of accumulators (i.e. deductible and out-of-pocket limits) for each benefit type.

"Often different benefit types are administered by different claim adjudication systems, e.g., three separate systems to handle medical, pharmacy and behavioral claims. In order for these systems to properly apply a claim against a member's shared deductible and out-of-pocket limits, they each must be aware of the claims the other systems may have adjudicated for that member and the cost share amount applied to the shared accumulators. In a simple scenario, with three systems administering three different benefit types, medical, pharmacy and behavioral, there are numerous interfaces and exchanges that are needed. For instance, the medical system sends accumulator updates to the pharmacy and behavioral systems for medical claims; and pharmacy and behavioral systems need to send the medical system accumulator updates for a pharmacy claim or behavioral claim, respectively.

"Further, for complex health care systems operating multiple medical systems, specialty benefit systems and external delegated entities, the number of interfaces needed to support the accumulator update process grows dramatically. Moreover, these interfaces are typically developed as 'one-offs' where each interface has its own requirements and specifications. Consequently, there is a great deal of overlap and costs to maintaining and adding new interfaces. This problem is exacerbated by the advent of health care reform, whereby commercial medical plans need to include pharmacy, behavioral, physical health, dental and vision benefits as part of the core medical benefits with one set of shared accumulators.

"Currently these interfaces are handled by each system receiving and sending file based updates to the other system. Typically these updates are grouped together based on a specified time interval and submitted in batches. This results in timing issues when a member submits multiple claims for different benefit types within a short duration of time. For instance, a member submits a $200 medical claim and a $100 pharmacy claim on the same day. Also assume the member's current out-of-pocket balance is $1800 and the maximum is set at $2000. The medical system processes the claim applying the $200 toward the out-of-pocket. The member's out-of-pocket maximum has now been reached but the medical system does not send the update to the pharmacy system until several days later as part of a batch process it runs. Meanwhile, the pharmacy system receives the $100 claim and also applies it toward the member's out-of-pocket since it is not aware of the $200 medical claim that was already processed. As a result the member has been charged an additional $100 when in fact the out-of-pocket maximum has already been reached. The member is dissatisfied and reports the issue, requiring the insurance company to investigate the matter, reconcile claims and correct the problem. Consequently, there is a need to provide a way to manage accumulator updates between multiple systems."

In addition to obtaining background information on this patent, NewsRx editors also obtained the inventor's summary information for this patent: "The present disclosure provides a centralized accumulator for managing the exchange and acknowledgement of accumulator updates between multiple systems, such as claim adjudication engines, utilizing shared accumulators.

"According to one implementation, a computer-implemented method manages healthcare costs accumulated across a plurality of claims systems. The method involves using a computer processor that executes the steps to manage such accumulated costs. The processor receives cost accumulator data for a plurality of adjudicated claims from a plurality of sending claim systems. For instance, the cost accumulator data includes an accumulated cost for healthcare services received by the member over a selected period of time. The processor identifies an accumulator record type from the cost accumulator data. These record types include an adjudicated claim, an initial accumulator record, an update accumulator record and an acknowledgement accumulator record. A cross-reference record is generated by the processor for the cost accumulator data according to the accumulator data type. A routing message is generated by the processor for at least one receiving claim system different from the sending claim system, and in generating the message, the processor uses a) the identified accumulator record type, b) the cost accumulator data received from the sending claim system, and c) an identity of the at least one receiving claim system. The routing message is routed to the at least one receiving claim system by the processor, and at least one of an initial, an update or an acknowledgement accumulator record is received by the processor from the at least one receiving claim system, which is used to update the cross-reference record by the processor.

"According to another implementation, a computer system for managing healthcare costs accumulated across a plurality of claims systems uses one or more computer processors to manage such costs. The processors receive adjudicated claim data for a plurality of adjudicated claims from a plurality of sending claim systems. Cost accumulator records are generated by the processors using the adjudicated claim data for each of the plurality of members. These records may include, for instance, an accumulation of healthcare costs incurred over a pre-defined time period. For each of the plurality of cost accumulator records, accumulated costs are separated into deductible cost accumulator records and out-of-pocket cost accumulator records. In addition, for each of the deductible cost accumulator records and the out-of-pocket cost accumulator records, the accumulated costs incurred within a network for a health plan of a member are separated from accumulated costs incurred outside of the network. Consequently, four cost accumulator types are generated including a deductible in-network cost accumulator, a deductible out-of-network cost accumulator, an out-of-pocket in-network cost accumulator, and an out-of-pocket out-of-network cost accumulator. A plurality of these cost accumulator types are routed to a plurality of receiving claim systems, which share cost accumulators at least one of the sending claim systems, and an acknowledgement from the receiving claim systems is received by the processors. Such an acknowledgement includes a record of the receiving claim system's cost accumulator records for the plurality of the cost accumulator types routed.

"In yet another implementation, a computer-implemented method for managing healthcare costs accumulated across a plurality of claims systems involves using a computer processor to manage these costs. The computer processor receives claim data for at least one claim for a member of a health plan. The claim data is received from one of a first medical or non-medical claim system and includes accumulated cost of services received by the member under the health plan over a pre-defined period of time. An accumulator record is generated by the processor using the accumulated cost of services received, and the processor routes the accumulator record to another of the medical or non-medical claim system having an accumulator shared with the first medical or non-medical claim system. An acknowledgement accumulator record is received by the processor from the another claim system, and the acknowledgement accumulator record includes the another claim system's accumulated cost of services for the member under the health plan.

"It will be understood the operations may be performed by one processor or multiple processors operating in concert, and the one or more processors may be implemented using one or more servers."

The claims supplied by the inventors are:

"What is claimed is:

"1. A computer system for managing healthcare costs accumulated across a plurality of claims systems, the system comprising one or more computer processors performing the steps of: receiving adjudicated claim data or a received initial accumulator record for a plurality of adjudicated claims from a plurality of sending claim systems at a central accumulator, the adjudicated claim data or the received initial accumulator record for a plurality of members under a plurality of health plans; generating cost accumulator records using the adjudicated claim data or the received initial accumulator record for each of the plurality of members, wherein the cost accumulator records comprise an accumulation of healthcare costs incurred over a pre-defined time period; storing the cost accumulator records in an accumulator header table; for each of the plurality of cost accumulator records stored in the accumulator header table, separating accumulated costs into deductible cost accumulator records and out-of-pocket cost accumulator records; for each of the deductible cost accumulator records and the out-of-pocket cost accumulator records, separating accumulated costs incurred within a network for a health plan of a member from accumulated costs incurred outside of the network thereby generating four cost accumulator types including a deductible in-network cost accumulator, a deductible out-of-network cost accumulator, an out-of-pocket in-network cost accumulator, and an out-of-pocket out-of-network cost accumulator; validating the cost accumulator records by querying the accumulator header table based on a cost accumulator sub-type associated with each cost accumulator record; routing a plurality of the cost accumulator types from the central accumulator to a plurality of receiving claim systems, wherein the receiving claim systems share cost accumulators with at least one of the sending claim systems; receiving an acknowledgement from the receiving claim systems at the central accumulator, the acknowledgement comprising a record of the receiving claim system's cost accumulator records for the plurality of the cost accumulator types routed.

"2. The system of claim 1, wherein the step of routing a plurality of the cost accumulator types from the central accumulator to a plurality of receiving claim systems comprises writing at least one routing message for each of the receiving claim systems, the at least one routing message containing one of the four cost accumulator types.

"3. The system of claim 2, wherein the at least one routing message is written using one of the four cost accumulator types supported by the receiving claim system targeted for the routing message.

"4. The system of claim 2, wherein the at least one routing message comprises one of a routing initial accumulator record, an update accumulator record or an acknowledgement accumulator record.

"5. The system of claim 4, wherein: when the at least one routing message is written using a post-adjudicated claim, the routing message is the routing initial accumulator record; and when the at least one routing message is written using the received initial accumulator record, the routing message is an update accumulator record.

"6. The system of claim 1, wherein the step of receiving an acknowledgement from the receiving claim systems comprises receiving the acknowledgement from a non-medical claim system, and the one or more processors further performing the step of routing another acknowledgement accumulator record from the central accumulator to the medical claim system, the another acknowledgement accumulator confirming receipt of the acknowledgement accumulator record."

For more information, see this patent: Zielinski, Thomas E. Centralized Accumulator Systems And Methods. U.S. Patent Number 10,042,982, filed May 19, 2014, and published online on August 20, 2018. Patent URL: http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=10,042,982.PN.&OS=PN/10,042,982RS=PN/10,042,982

Keywords for this news article include: Business, Computers, Minnesota, Minnetonka, Managed Care, United States, Health and Medicine, North and Central America, UnitedHealth Group Incorporated.

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