Patent Issued for Electronic pharmacy adjudication system and associated method and computer program product (USPTO 11783424): Express Scripts Canada Co.
2023 OCT 27 (NewsRx) -- By a
Patent number 11783424 is assigned to
The following quote was obtained by the news editors from the background information supplied by the inventors: “Pharmaceuticals are usually sold through a third-party payment system in which pharmacies look directly to insurers or other obligors for primary payment. Pharmacies must rely on the payment practices and creditworthiness of third parties to collect for prescriptions provided to customers covered by a third-party payment plan.
“The conventional prescription claims processing and payment system involves one or more entities providing one or more of a variety of functions. Generally, these parties include: the pharmacy, switch, processor and obligor.
“In this context, a patient may make a claim under a health plan through the patient’s pharmacy at the time the prescription is filled. Today most conventional pharmaceutical claims are adjudicated using an electronic on-line system. Pharmacies generally submit claims in real-time to a claims adjudication network for processing. Conventional systems for electronic claims adjudication by pharmacy benefits management (“PBM”) companies have been around for some time. A PBM is an administrator of prescription drug programs. PBMs are primarily responsible for adjudication and paying claims for covered prescription drugs that are purchased by consumers who are members of the prescription drug benefit program. Other typical PBM services include developing and maintaining the drug formulary (the list of drugs covered by the prescription drug benefits program and their associated tiers), contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers. Conventional PBM claim adjudication systems are typically employed when a member attempts to purchase a drug and the drug purchase is to be wholly or partially covered by a prescription drug benefits program. A prescription drug benefits program may be provided to the member through an employer health plan (e.g., ERISA plans, self-insured plans, managed care plans, Taft-Hartley trust plans, etc.), or a privately purchased health plan, a government sponsored plan (e.g., Medicare, Medicaid or any other city, state/province or local or federal government plan) or directly from a PBM provider. In such a transaction, the originating entity (e.g., a pharmacy) electronically transmits a claim to the PBM through a switch company for adjudication of the claim. The PBM adjudicates the claim to validate, among other things, that the member has a valid prescription drug benefits program, that the prescribing doctor is valid, and that the drug is covered by the prescription drug benefits program. The PBM sends an electronic response back to the pharmacy that denies the transaction or approves the transaction and also identifies the co-pay amount.
“At a high level, the overall process of adjudicating drug purchase claims covered by the variety of prescription drug benefits programs offered under various types of health care plans is similar such that the pharmacy electronically transmits a claim to the PBM, the claim is adjudicated, and an electronic response is sent back to the pharmacy.
“One challenge for systems implementing on-line adjudication processes for prescription drug purchase claims is that they are required to adjudicate very large number of claims within a reasonable delay to allow an insured user to receive an adjudication decision corresponding to the healthcare insurance claim when he is on location at a pharmacy filling his/her prescription. For example, Express Scripts Canada processes on average over 300,000 pharmacy claims per day, which annually translates to over 100 million claims. General guidelines required that each claim be processed in under 0.5 seconds.
“In some cases, adjudication is performed using rules-based decision management systems. These systems comprise various logic rules that are configured to output decisions on the basis of data fed to the systems via one or more databases. In a typical system, an insurance claim is processed against many rules during the claim’s adjudication lifecycle and the complexity of the rules can vary from simple to extremely complex. Patient historical data is typically required to process some of the claims adjudication rules and this data can be in the range of a current year, to many years of historical data. In the context of prescription drug purchase, databases that pertain to millions of users and span over decades may be required to provide full coverage of the adjudication service. As the complexity of the healthcare insurance claims increases, for example due to the number of possible combinations/conditions in the types of health benefits, the performance of these rules-based decision management systems is often unsatisfactory for generating adjudication decisions within the expected delays and, in some cases, these systems fail altogether. Dependencies between rules also create risk, complexity and make changes to rules more expensive. In typical pharmacy adjudication system there may be over 4,000 atomic rules in the adjudication system and the execution of these rules including information provided in the health insurance claim, plan design, and result of rules executed. As a consequence, the control and flexibility in the type of claims that can be electronically processed for adjudication is limited.
“Against the background described above, it is clear that there remains a need in the industry to provide improved systems and methods for performing an adjudication service in connection with a healthcare insurance claim originating from a point of sale (POS) device that alleviate at least some of the deficiencies of the existing systems and methods.”
In addition to the background information obtained for this patent, NewsRx journalists also obtained the inventors’ summary information for this patent: “This Summary is provided to introduce a selection of concepts in a simplified form that are further described below in the Detailed Description. This Summary is not intended to identify key aspects or essential aspects of the claimed subject matter.
“In accordance with a first aspect, an electronic pharmacy adjudication system is provided for performing an adjudication service in connection with a healthcare insurance claim originating from a point of sale (POS) device. The electronic pharmacy adjudication system includes one or more processors and a non-transitory computer readable memory storing computer program instructions. The computer program instructions when executed implement the following:”
The claims supplied by the inventors are:
“1. An electronic pharmacy adjudication system for performing an adjudication service in connection with healthcare insurance claims originating from a plurality of point of sale (POS) devices, said electronic pharmacy adjudication system comprising: one or more processors; and a non-transitory computer readable memory storing computer program instructions, the computer program instructions when executed by the one or more processors implementing: a) an interface layer in communication with a data network configured for: i) receiving the healthcare insurance claims originating from the point of sale (POS) devices, each of the healthcare insurance claims including a plurality of information data elements specifying characteristics of the healthcare insurance claim; ii) releasing results for transmittal to the point of sale (POS) devices, the results conveying an adjudication decision corresponding to each of the healthcare insurance claims; b) a service and rules engine layer configured for: i) receiving a service call identifying a set of parameters on which the service call is to be applied; and ii) deriving a partial decision result at least in part by processing the set of parameters identified by the service call according to one or more decision rules from a rules repository, the one or more decision rules corresponding to the service call and being a subset of decisions rules in the rules repository; c) an orchestration layer in communication with said interface layer and said service and rules engine layer, said orchestration layer being configured for: i) processing the information data elements in at least 20,000 of the healthcare insurance claims to generate a sequence of service calls for each of the at least 20,000 of the healthcare insurance claims and forwarding a first service call in the sequence of service calls to the service and rules engine layer to derive a first partial decision result corresponding to the first service call; ii) forwarding one or more subsequent service calls in the sequence of service calls to the service and rules engine layer to derive one or more subsequent partial decision results in a sequence of partial decision results when the adjudication decision corresponding to a respective one of the at least 20,000 of the healthcare insurance claims cannot be derived from a previous partial decision result in the sequence of partial decision results corresponding to a previous service call in the sequence of service calls; iii) processing the sequence of partial decision results generated by the service and rules engine layer in response to the generated sequence of service calls to incrementally derive the adjudication decision corresponding to each of the at least 20,000 of the healthcare insurance claims; iv) forwarding the derived adjudication decision corresponding to each of the at least 20,000 of the healthcare insurance claims to the interface layer for transmittal to a respective one of the point of sale (POS) devices.
“2. An electronic pharmacy adjudication system as defined in claim 1, wherein the service and rules engine layer is in communication with the rules repository, the rules repository containing business rules associated with healthcare insurance.
“3. An electronic pharmacy adjudication system as defined in claim 2, wherein said system comprises a computer readable storage medium storing the rules repository containing the business rules associated with healthcare insurance.
“4. An electronic pharmacy adjudication system as defined in claim 1, wherein the service and rules engine layer is in communication with a data repository containing health insurance information for a plurality of insured users.
“5. An electronic pharmacy adjudication system as defined in claim 4, wherein the data repository contains lists of drugs covered by a prescription drug benefits programs for at least some of the plurality of insured users.
“6. An electronic pharmacy adjudication system as defined in claim 4, wherein said system comprises a computer readable storage medium storing the data repository containing the health insurance information for a plurality of insured users.
“7. An electronic pharmacy adjudication system as defined in claim 4, wherein the service and rules engine layer is configured for: a) processing the service call to identify in the data repository a data set for use by the service call; b) deriving the partial decision result at least in part by processing data in the identified data set and the set of parameters identified by the service call according to the one or more decision rules corresponding to the service call.
“8. An electronic pharmacy adjudication system as defined in claim 7, wherein processing the service call to identify in the data repository a data subset for use by the service call includes: i) processing the one or more decision rules to identify in the data repository a corresponding data subset for each decision rule amongst the one or more decision rules; ii) executing each of the one or more decision rules at least in part by processing at least some of the set of parameters identified by the service call and the corresponding data subset.
“9. An electronic pharmacy adjudication system as defined in claim 1, wherein the rules repository includes one or more rules that apply to a specific insurance carrier, the one or more rules including rules selected from the set consisting of: a) core adjudication rules; b) legislative rules; c) rules pertaining to insurance programs developed by the specific insurance carrier and made available to all insurance carriers; and d) rules pertaining to insurance programs developed by the specific insurance carrier and only available to the specific insurance carrier.
“10. An electronic pharmacy adjudication system as defined in claim 1, wherein the service and rules engine layer is configured for: i) processing the service call to identify in the rules repository the one or more decision rules corresponding to the service call; ii) executing the one or more decision rules identified in the rule repository to derive the partial decision result, wherein executing the one or more decision rules includes processing at least some of the set of parameters identified by the service call.
“11. An electronic pharmacy adjudication system as defined in claim 1, wherein the sequence of service calls generated by the orchestration layer includes one or more service calls selected from the set consisting of an eligibility verification service call, a benefit verification service call and a cost verification service call.
“12. An electronic pharmacy adjudication system as defined in claim 1, wherein said orchestration layer being configured for processing the information data elements in the at least 20,000 of the healthcare insurance claims to generate the sequence of service calls at least in part by: in response to receipt of the partial decision result corresponding to the first service call, selectively generating a second service call at least in part by processing the partial decision result corresponding to the first service call.
“13. An electronic pharmacy adjudication system as defined in claim 12, wherein the first service call includes an eligibility verification service call and wherein the second service call includes a benefit verification service call.
“14. An electronic pharmacy adjudication system as defined in claim 1, wherein the sequence of service calls generated by the orchestration layer includes one or more service calls selected from the set consisting of a claim validation service call, an eligibility verification service call, a benefit verification service call, a cost verification service call and a claim persistence service call.
“15. An electronic pharmacy adjudication system as defined in claim 1, wherein the sequence of service calls includes the first service call and at least a second service call distinct from the first service call and wherein the orchestration layer being configured for forwarding the first service call to the service and rules engine layer prior to transmitting the second service call to the service and rules engine layer.
“16. An electronic pharmacy adjudication system as defined in claim 1, wherein the plurality of information data elements specifying characteristics of the healthcare insurance claim includes patient information, insurance plan information and healthcare treatment information.
“17. An electronic pharmacy adjudication system as defined in claim 16, wherein the healthcare treatment information including information conveying drug prescription information.”
There are additional claims. Please visit full patent to read further.
URL and more information on this patent, see: Griffin,
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