Patent Issued for Healthcare System And Method For Right-Time Claims Adjudication And Payment (USPTO 10,311,207)

2019 JUN 17 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- According to news reporting originating from Alexandria, Virginia, by NewsRx journalists, a patent by the inventors Kennedy, Beverly (Greenwood Village, CO); Bartlett, Robyn (Omaha, NE), filed on June 20, 2014, was published online on June 17, 2019.

The assignee for this patent, patent number 10,311,207, is First Data Corporation (Greenwood Village, Colorado, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “The present invention relates to systems and methods for paying healthcare charges, particularly where the charges may be allocated among more than one payment source.

“Healthcare costs are an issue of significant concern to the government, consumers, health insurance companies and healthcare providers (physicians, hospitals, pharmacies, etc.). Healthcare costs comprise an increasing and disproportionate share of the U.S. economy. There have been many factors identified as leading to these increases in cost. One such factor is the administrative cost in delivering and billing for healthcare services (administrative costs have been estimated to account for as much as 25% or more of the typical healthcare charge). Closely tied to this is a the lack of financial accountability by many providers (due to the typical patient not being aware of or responsible for the overall cost of received healthcare services). For example, a relatively ‘routine’ hospital stay can easily exceed $10,000, and even with a deductible paid by the patient (say, $500), very little of the total cost is paid by the patient. There is little incentive for the patient to review and question the accuracy of the invoice for services performed at the hospital (when, in fact, the patient may be in the best position to know whether individual services charged were provided or even requested).

“Changes are occurring in the healthcare system in order to control costs. One such change has been the increasing use of ‘consumer-driven’ healthcare insurance policies or plans. These plans often feature a high annual deductible (e.g., $5,000), coupled with a medical savings account (MSA). The consumer contributes to the MSA (usually pre-tax) and may be able to accumulate significant funds over time in which to pay for medical costs not covered by the high deductible insurance policy. The payment of charges from an account ‘owned’ by the consumer is believed by many to lead to more careful decisions by consumers who may be requesting and monitoring the cost of medical services.

“Consumer-driven programs may result in financial/accounting difficulties for some providers. It may be difficult for the consumer and for the provider (particularly a physician at a small medical office without sophisticated billing or transaction processing systems), to keep track of an annual deductible and how an individual charge may be allocated between an insurance company (or other third party payer) and a consumer. At the time of rendering the service, a provider often will have no data available for indicating whether or not a deductible has been met (prior charges applied to the deductible may have been billed by other providers), and such data can be obtained only by submitting a claim to the consumer’s insurance company. Further, an important feature of most healthcare policies is that the consumer is able to take advantage of a schedule of ‘authorized’ or ‘permitted’ charges for specific services (usually identified by treatment codes) that are governed by an agreement negotiated between the provider and the insurer. Such permitted charges are usually far less than the full, undiscounted charge to be paid by someone without insurance. The provider has agreed with the insurer to receive no more than the permitted charge for services provided to covered consumers. Thus, even if the deductible has not been met (which will usually be the case for a person without large annual medical bills), the amount to be paid by the consumer will not be the physician’s ‘normal’ charge, but rather the insurer’s ‘permitted’ charge. Unfortunately, many providers have contracts with multiple insurance companies, health maintenance organizations (HMOs), or other healthcare payers, and the discounts (and ultimate charges to be paid) for the same services are not the same, but rather will vary from patient to patient (depending on the insurance program that covers the patient). Many providers are unable to confirm the permitted charge until after a claim is submitted and adjudicated by the insurance company.

“It can therefore be long after a healthcare service is provided that a charge becomes payable by the consumer. The provider will first submit a claim to the consumer’s insurer, and wait for a claim adjudication--usually in the form of an ‘Explanation of Benefits’ (EOB) statement to the consumer from the insurer (a similar statement usually sent at the same time to the provider is often referred to as an ‘Explanation of Payment’ or ‘EOP’). The EOB will show the permitted charge for the services, and in those cases where the deductible has not been met, confirm that the permitted charge is the patient’s responsibility. While the EOB will provide confirmation of what is to be paid by the consumer, it will often take weeks (sometimes months) for the EOB to issue and for the provider to thereafter bill for the permitted charge and to then receive payment from the consumer. In cases where a provider has many patients with ‘high deductible’ plans, a provider may have substantial outstanding charges that are awaiting a determination of the permitted amount and a determination of the paying party (insurance company or consumer). For an individual provider, the delay in receiving such payments can be a significant financial burden.”

In addition to obtaining background information on this patent, NewsRx editors also obtained the inventors’ summary information for this patent: “There is provided, in accordance with embodiments of the present invention, a network/system and method for providing claim adjudication and payment for a healthcare charge.

“In one embodiment, a system provides right-time payment for patient healthcare services to a provider of such services. The system includes a point of sale (POS) device for use by the provider in entering patient information, including at least patient ID information and a healthcare treatment code, and a host for receiving the patient information from the POS device for submission as a healthcare claim to a first payer source. The host also provides estimated explanation of benefits (EOB) information. The estimated EOB information includes at least information on any patient portion of a provider charge that is not to be paid by the first payer source, so that the patient may pay the patient portion on a real-time basis to the provider in response to the estimated EOB information.

“In another embodiment, the first payer subsequently returns actual (non-estimated) EOB information, and such actual EOB information is reconciled against the earlier estimated EOB information.

“In some embodiments, claim adjudication may be achieved by estimating amounts to be paid (e.g., to be paid by a third party payer or by the patient), in response to a healthcare claim. In other embodiments, some payers provide real-time claim adjudication and some do not. The system may receive real-time, actual EOB information relating to some payers (real-time adjudication of a claim) and estimated EOB information relating to other payers (e.g., an estimating system estimates EOB information, but actual adjudication and actual EOB information may be provided later). In either instance, payment can be made by the patient based on information provided at the time a healthcare claim is made. This type of transaction, where payment may be made by a patient immediately (based on either estimated or actual EOB information), is sometimes referred to herein as ‘right-time’ claim adjudication.

“A more complete understanding of the present invention may be derived by referring to the detailed description of the invention and to the claims, when considered in connection with the Figures.”

The claims supplied by the inventors are:

“What is claimed is:

“1. A system for providing right-time claim adjudication and payment for patient healthcare services that are provided at a provider location, where payment may be made by multiple payer sources, the system comprising: a point of sale (POS) device for use by a provider in entering patient information for a patient, including at least patient ID information associated with the patient and a healthcare treatment code for the patient healthcare services provided to the patient; a display device communicatively coupled to the POS device; a host computer for receiving the patient information from the POS device, for submitting the patient information as a healthcare claim to a first payer source after the patient healthcare services have been provided to the patient, for submitting the patient information to an estimating system, for receiving from the estimating system estimated explanation of benefits (EOB) information in the form of an estimated EOB statement and in response to the healthcare claim, and for providing the estimated EOB information to the EOS device for display at the display device, the estimated EOB information generated by the estimating system as an estimated adjudication of the healthcare claim and including at least information on an estimated patient portion amount of a provider charge that is not to be paid by the first payer source; whereby the patient authorizes payment of the patient portion on a real-time basis to the provider while the patient is at the provider location in response to the estimated EOB information displayed at the display device associated with POS device; and wherein the first payer source provides to the host computer final EOB information in the form of a final EOB statement in response to the healthcare claim to the first payer source and based on adjudication of the healthcare claim, the final EOB information separate from the estimated EOB information, and wherein a patient portion amount in the separate final EOB information is reconciled against the patient portion amount, in the estimated EOB information.

“2. The system of claim 1, wherein the estimated EOB information further includes information relating to a permitted charge corresponding to the treatment code.

“3. The system of claim 1, wherein the patient authorizes payment of the patient portion from a second payer source.

“4. The system of claim 3, wherein the second payer source is selected from a group consisting of a credit card account, debit card account, MSA, or a bank account.

“5. The system of claim 4, wherein the host computer receives information on the second payer source and electronically posts the amount of the patient portion as a transaction against the second payer source.

“6. The system of claim 4, wherein the host computer receives information on the second payer source, and wherein the second payer source is a credit card account and wherein authorization of payment is a reserve against a credit limit for the account.

“7. The system of claim 5, wherein the estimated EOB information further includes information on a permitted charge corresponding to the patient information.

“8. The system or claim 1, wherein the host computer is operated by a third party transaction processing entity, wherein the third party transaction processing entity is a party other than the provider and the first payer source.

“9. The system of claim 1, wherein the host computer is operated by the provider.

“10. The system of claim 1, wherein the display device associated with the POS device displays information on at least one of the payer sources other than the first payer source, so that the other payer source may be selected for the patient portion, thereby permitting real-time payment of the patient portion by the selected payment source, while the patient is at the provider location.

“11. The system of claim 10, wherein the first payer source is a healthcare insurer, and wherein the selected other payer source is an MSA account.

“12. The system of claim 10, wherein the first payer source is a healthcare insurer, and wherein the selected other payer source is a financial account maintained by the patient.

“13. The system of claim 12, wherein the financial account maintained by the patient is a credit card account.

“14. The system of claim 12, wherein the financial account maintained by the patient is a banking account.

“15. The system of claim 1, wherein the host computer determines whether the first payer is able to provide real-time adjudication of the healthcare claim, and submits the healthcare claim to the estimating system when the first payer is not able to provide real-time adjudication of the healthcare claim.

“16. A method for making payment on a charge from a provider for healthcare services that are provided to a patient at a provider location, wherein the services are subject to a healthcare plan administered by a first payer, and wherein a patient portion amount of the charge may not be covered by the healthcare plan, and wherein a second payer may be used for the patient portion, the method comprising: providing a healthcare provider system at the provider location, the provider system having a point of sale (POS) device for receiving a patient ID and a treatment code identifying healthcare services provided to the patient, and the provider system for identifying the first payer; electronically preparing a claim at the provider system for the first payer, the claim including the patient ID ) and the treatment code, after the patient healthcare services have been provided; transmitting the claim from the provider system to the first payer and to an estimating system; generating estimated EOB data at the estimating system as an estimated adjudication of the claim and in response to the claim, and transmitting the estimated EOB data to the provider system, the estimated EOB data representing at least the patient portion amount; displaying the estimated EOB data at a display device associated with the POS device at the provider system for the patient to authorize payment from the second payer for the patient portion amount based on the estimated EOB data; electronically submitting an authorization for payment from the provider system to a second payer system, in order to process real-time payment from the second payer while the patient is at the provider location; subsequently receiving at the provider system non-estimated EOB data from the first payer in response to the claim and that is separate from the estimated EOB data; and reconciling the non-estimated EOB data against the estimated EOB data.

“17. The method of claim 16, wherein the patient ID is received at the provider system by reading a presentation instrument.

“18. The method of claim 16, wherein a processing system operated by a third party processing entity generates the estimated EOB data, submits the claim to the first payer system, processes authorization for payment to the second payer system, and reconciles the non-estimated EOB data against the estimated EOB data, and wherein the third party processing entity is a party other than the provider, the first payer and the second payer.

“19. The method of claim 16, wherein the healthcare plan is a high deductible plan.

“20. A system for making payment for patient healthcare services to a provider of such services, where payment may be made by multiple payer sources, including a first payer to whom a health care claim is submitted and a second payer maintaining an account on behalf of the patient that may be used for amounts not paid by the first payer, the system comprising: a point of sale (POS) device for use by the provider in entering data, including at least a patient identification and a treatment code; a display device associated with the POS device; and a healthcare network linked to the POS terminal and to the second payer, the healthcare network for: receiving data entered at the POS terminal and in response to the received data electronically transmitting a healthcare claim to the first payer source and to an estimating system, after patient healthcare services have been provided to the patient; receiving from the estimating system an estimated explanation of benefits (EOB) message in response to the healthcare claim and after patient healthcare services have been provided to the patient, as an estimated adjudication of the healthcare claim, the estimated EOB message provided to the POS device for display at the display device, the estimated EOB message including at least (a) information on a permitted charge corresponding to the treatment code and (b) information relating to a patient portion of such permitted charge that is not to be paid by the first payer; and posting an electronic transaction against the second payer account in response to receipt of the patient portion information, so that real-time payment of the patient portion to the provider may be made while the patient is at the provider location and after the estimated EOB message is received by the healthcare network and provided to the POS device; wherein the healthcare network subsequently receives a non-estimated EOB message from the first payer in response to the healthcare claim, and where a patient portion of the non-estimated EOB message is reconciled by the healthcare network against the patient portion of the estimated EOB message; and wherein the difference between the estimated EOB information and the non-estimated EOB information is used by the estimating system as a basis for calculating estimated EOB information for subsequent healthcare claims transmitted to the estimating system.

“21. The system of claim 20, wherein: the POS device receives information relating to the second payer account while the patient is at the provider location; the healthcare network assigns a reference identifier associated with the second payer account and associates the reference identifier with the healthcare claim; and the healthcare network uses the reference number to identify the second payer account when the estimated EOB is received from the estimating system, in order to post a transaction against the second payer account.

“22. The system of claim 21, wherein the healthcare network includes a host computer linked to the POS device and to the second payer.

“23. The system of claim 22, wherein the healthcare network includes the estimating system, wherein the healthcare network is operated by a third party processing entity, and wherein the third party processing entity is a party other than the provider, the first payer and the second payer.”

For more information, see this patent: Kennedy, Beverly; Bartlett, Robyn. Healthcare System And Method For Right-Time Claims Adjudication And Payment. U.S. Patent Number 10,311,207, filed June 20, 2014, and published online on June 17, 2019. 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=10,311,207.PN.&OS=PN/10,311,207RS=PN/10,311,207

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