Patent Issued for Medical claims payment methods and systems (USPTO 11443279): Electronic Commerce for Healthcare Organizations Inc.
2022 SEP 30 (NewsRx) -- By a
The assignee for this patent, patent number 11443279, is Electronic Commerce for
Reporters obtained the following quote from the background information supplied by the inventors: “The present invention pertains to the payment of insurance, particularly medical insurance claims.
“Currently, there are thousands of medical health insurance plans. Major employers negotiate custom medical insurance plans for their employees. Other companies select one of several insurance plans offered by an insurance company which may or may not include various options. Small business associations negotiate yet other health insurance contracts. The employees within these various employer groups obtain medical services at a plurality of covered medical facilities. Conversely, the various medical facilities treat patients with a myriad of different health plans.
“The Employee Retirement Income Security Act (ERISA) prohibits the co-mingling of health insurance payments. A single instrument, such as a check, cannot be issued that shares risk. This results in insurance companies issuing a very large number of checks, and medical providers receiving large numbers of checks. Fulfillment vendors function as a go-between between the payers and the medical service providers. However, they too are bound by the ERISA rules against co-mingling of funds and must take care to avoid co-mingling funds received from payers and print or produce a multitude of checks to the various medical providers. Typically, a fulfillment vendor must send a medical provider a different and separate check for funds from each payer.
“The funds are accompanied by an Explanation of Benefits (EOB) which is formatted and the contents normalized to the ANSI-835 standard. However, the normalized content is not standardized from employer group to employer group. Even though the normalized content may specify such terms as “non-covered” or “pending”, different health insurance contracts give different meanings to these terms. For example, a “non-covered” service in from one contract can mean that the service provider must write-off the amount while in another contract the insured is responsible for payment of the “non-covered” amount. Secondary insurers add other possible interpretations of “non-covered”. It is often difficult for the medical provider to determine, to a certainty, such simple information as the patient’s co-pay, what amounts may be billed to the patient, which amounts must be written off, and the like. Determining this information generally requires a custom interpretation of the EOB from each of the various employer groups. Such individual interpretation is labor-intensive and expensive to the medical service providers. Moreover, due to the uncertainty regarding which charges must be written off and which may be billed to the patient, patients are often billed for charges which their insurance contract requires to be written off.
“Only certain financial instruments meet ERISA regulations against co-mingling of funds. Certain legal entities such as trusts may be required for use of certain financial instruments. In addition, not all payees accept all types of financial instruments. Some financial instruments require electronic methods and access to certain networks and/or servers. Furthermore the financial instrument used to move funds and the EOB are intrinsically linked. A particular financial instrument may require a specific type of format for transmission of associated EOBs. As new financial instruments are developed and/or options for EOB formats permitted, system complexity for incorporation of new payment methods grows quickly.
“A medical claims processing system typically implements one or several methods of payment. As new payment methods are developed, and the cost structure becomes more attractive, payers purchase or subscribe to these new payment methods with additional systems and/or subscriptions. However, interfaces between systems or providers for access to alternative methods add cost and complexity to tracking of payments and EOBs. Some payment methods have rejections such as the service provider is no longer with the payee, the payment may be refused by the payee such as with a stored value card, the payee may have changed banks and the financial instrument is not valid, and the like. A rejection of a payment causes the payer to seek an alternative payment method. An alternative payment method can have a different format for either or both the financial instrument and the EOBs, and force a payer to a different system with tracking and continual prevention of co-mingling funds between multiple systems.
“The present application provides a new and improved automated payment system with an intelligent router of payments which overcomes these problems and others.”
In addition to obtaining background information on this patent, NewsRx editors also obtained the inventors’ summary information for this patent: “In accordance with one aspect, a method of paying medical claims uses one or more processors to receive a payer payment method preferences which include an order of payment methods to each payee. A payment method is formatted and includes a consolidated financial instrument and at least one explanation of explanation of benefit associated with the consolidated financial instrument. The consolidated financial instrument transfers accumulated monies without co-mingling funds in compliance with ERISA regulations. The at least one associated explanation of benefit includes a patient identification, a payer identification, a service provider identification, a date of service, a service identification, and an amount paid. The formatted payment method are periodically sent to each payee with a coordinated transfer of the consolidated financial instrument and the at least one associated explanation of benefits. The steps of formatting and sending the payment method are repeated for each method preference in order until the transfer is accepted by each payee. The acceptance of the consolidated financial instrument and the at least one associated explanation of payment to each payee is recorded in a data store.
“In accordance with another aspect, a medical claims payment system includes one or more servers configured to receive a payer payment method preferences which include an order of payment methods to each payee. A payment is formatted and includes a consolidated financial instrument and at least one explanation of explanation of benefit associated with the consolidated financial instrument. The consolidated financial instrument transfers accumulated monies without co-mingling funds in compliance with ERISA regulations. The at least one associated explanation of benefit includes a patient identification, a payer identification, a service provider identification, a date of service, a service identification, and an amount paid. The formatted payment is sent to each payee with a coordinated transfer of the consolidated financial instrument and the at least one associated explanation of benefits. The steps of formatting and sending each payment for each payment method is repeated in order until the transfer is accepted by each payee. Acceptance of the payment method to each payee is recorded in a data store.
“In accordance with another aspect, a medical claims payment system includes one or more servers configured to periodically format and send payments to one or more payee by specified payment methods in an order of payer preference until each payment is accepted. The payments include a consolidated financial instrument and at least one explanation of explanation of benefit associated with the consolidated financial instrument. The consolidated financial instrument transfers accumulated monies without co-mingling funds in compliance with ERISA regulations. The at least one associated explanation of benefit includes a patient identification, a payer identification, a service provider identification, a date of service, a service identification, and an amount paid. Acceptance of the payment by each payee is recorded in a data store.
“One advantage is that it reduces the number of paper checks processed and is particularly amenable to electronic funds transfers.
“Another advantage resides in the standardization of information regarding benefits which are the responsibility of the insurance company and benefits which are the responsibility of the patient.”
The claims supplied by the inventors are:
“1. A computer implemented method of paying adjudicated medical claims to medical service providers comprising: using one or more processors: a health insurance payment system electronically receiving a plurality of groups of a plurality of explanation of benefits (EOBs) for a plurality of respective health insurance payments of a plurality of adjudicated medical insurance claims, each group of EOBs from one of a plurality of payors, and each payor associated with one of a plurality of employer groups, and the health insurance payment system electronically receiving monies from each of the plurality of payors and depositing the received monies into a plurality of respective employer group settlement accounts of at least one financial institution with the employer group settlement accounts segregated by employer group and insurance carrier, and each associated EOB received in a memory associated with the one or more processors, each associated EOB including at least one adjudicated claim for one patient and one medical service provider and identification of a portion of the received monies allocated to the at least one adjudicated claim; the health insurance payment system segregately storing each associated EOB in an associated memory; the health insurance payment system including an EOB translator associated with an employee group format module and associated with a provider format module with each accessing associated content memory, wherein the translator and the associated employee group format module resolve semantic ambiguities and allocate a medical service provider billed amount to at least one of the respective health insurance payment amount, an adjustment amount and a patient obligation amount associated with each EOB stored in the associated memory from a received form, format, and content of the employer group; and the EOB translator and associated provider format module translate each associated semantically resolved EOB stored in the associated memory from a received form, format, and content of the employer group to a preferred payee form, format, and content of the one medical service provider in the associated EOB; the health insurance payment system concurrently electronically transferring monies from the plurality of employer group settlement accounts of the at least one financial institution to a plurality of service provider settlement accounts at the at least one financial institution associated with the respective employer group without co-mingling funds to accumulate monies from a plurality of the plurality of employer group settlement accounts in each service provider settlement account and sorting the translated EOBs by medical service provider, each service provider settlement account corresponding to one medical service provider, each electronic transfer of money from one employer group settlement account to one service provider settlement account based on the identified portion of monies in each EOB allocated to adjudicated claims of the corresponding one medical service provider; and the health insurance payment system electronically and concurrently transferring accumulated monies from the service provider settlement accounts to bank accounts of the medical service providers without co-mingling funds and transferring translated EOBs to electronic accounting systems of medical service providers, wherein electronically transferring of accumulated monies are payments maintained separated until the payment becomes the property of the medical service provider, wherein transferring of monies to each bank account of the medical service provider and transferring translated EOBs to each medical service provider includes a single consolidated payment from a single payor including a plurality of health insurance payments of a plurality of adjudicated medical insurance claims transferred from a single service provider settlement account to the bank account of the medical service provider and a plurality of translated EOBs associated with the single consolidated payment; and recording the receiving and transferring of monies and associated EOBs in a medical payment history memory.
“2. The computer implemented method according to claim 1, wherein the form, format, and content of the received associated EOBs includes ANSI 835 format.
“3. The computer implemented method according to claim 1, wherein the translator a co-pay of the patient based on at least one of a non-covered amount or a pending amount.
“4. The computer implemented method according to claim 1, wherein the translator determines a write-off amount based on at least one of a non-covered amount or a pending amount.
“5. The computer implemented method according to claim 1, wherein the translator determines an amount to be billed to the patient based on a non-covered amount or a pending amount.
“6. The computer implemented method according to claim 1, wherein a payment of the transferred monies includes a financial instrument issued by an issuing bank.
“7. The computer implemented method according to claim 6, wherein the instrument includes at least one of a bank draft, a credit card, a debit card, or a stored value card.
“8. The computer implemented method according to claim 1 including: tracing the record receipt and transfers of monies and the associated EOBs from receipt in the employer group settlement account and EOB memory to the bank account and electronic accounting system of the medical service provider.
“9. The computer implemented method according to claim 1, wherein the translator determines an amount to be written off and an amount for which the patient is responsible based on a received pending amount or a received non-covered amount and further comprising: emailing EOBs of the adjudicated claims for a family to a patient which specifies each amount paid to the service providers, the amounts required to be written off, and the amount for which the patient is responsible.
“10. The computer-implemented method according to claim 1, wherein a payment of the transferred monies includes a financial instrument issued by an issuing bank and the financial instrument is a stored value card.”
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