Patent Issued for Systems and methods of processing and reconciling healthcare related claims (USPTO 11217346): Accumulation Technologies LLC

2022 JAN 26 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- A patent by the inventors Eggertsen, John (Pittsfield Township, MI, US), Madonna, Andrew (Saline, MI, US), Pearce, Joshua (Northville, MI, US), Tugulan, Victor (Redford, MI, US), Way, Benjamin (Canton, MI, US), filed on October 17, 2018, was published online on January 4, 2022, according to news reporting originating from Alexandria, Virginia, by NewsRx correspondents.

Patent number 11217346 is assigned to Accumulation Technologies LLC (Livonia, Michigan, United States).

The following quote was obtained by the news editors from the background information supplied by the inventors: “The vast majority of healthcare expenses of individuals are partially or wholly paid for by entities that provide healthcare coverage (“Healthcare Risk Bearers”). These Healthcare Risk Bearers include employers and employee organizations (via sponsoring group health plans), health insurance companies (selling both individual and group policies), governments (e.g., Medicare and Medicaid), associations and many other entities. There are several types of health benefits provided by Healthcare Risk Bearers, such as hospital and doctor coverage, prescription drug coverage and mental health and substance abuse coverage. The Healthcare Risk Bearers establish demographic and benefit design requirements (“Eligibility Data”) that the individuals must satisfy to qualify for the healthcare benefits the Healthcare Risk Bearers sponsors.

“In order to pay healthcare providers’ bills, Healthcare Risk Bearers usually hire claim processors (“Claim Processing Vendors”). Often Healthcare Risk Bearers hire different Claim Processing Vendors for different coverages. For example, a third party administrator may process hospital and doctor claims while a Pharmacy Benefit Manager would process drug claims. Sometimes several Claim Processing Vendors are hired for the same coverages and same individuals, especially over time.

“The Claim Processing Vendors collect the Eligibility Data from the Healthcare Risk Bearers in preparation for receiving claims for payment from healthcare providers. When those claims are received, they are typically submitted and processed electronically. Once a claim has been adjudicated and processed by the applicable Claim Processing Vendor, information about the claim often should be communicated to several other Claim Processing Vendors who are working for the same Healthcare Risk Bearer (“Recipient Claim Processing Vendors”). In order for all Claim Processing Vendors to manage their portion of the Healthcare Risk Bearer’s benefit, the Claim Processing Vendors need information about claims processed by other Claim Processing Vendors managing other aspects of the Healthcare Risk Bearer’s benefit.

“When multiple Claim Processing Vendors are involved in data integration, there are varying parameters for the data. Because of the varying membership and plan information used by each Claim Processing Vendor, processing failures can result. Each Recipient Claim Processing Vendor anticipates receiving claims only if the claim data matches their internal expectations. If those expectations are not met in full, the Recipient Claim Processing Vendor will fail to post the claim. With this failure, the originating Claim Processing Vendor and the Recipient Claim Processing Vendor will not be synchronized and will deliver an inconsistent experience to the individual covered by the Healthcare Risk Bearer based upon different data. To the originating Claim Processing Vendor, a claim data set would be considered legitimate and would be tagged within the originating Claim Processing Vendor’s system as a legitimate claim but would not be so treated by the Recipient Claim Processing Vendor. The originating Claim Processing Vendor has no control over the Recipient Claim Processing Vendor system in order to override failures caused by data mismatches or inconsistencies. Instead, both Vendors must use resources to manually reconcile claim-posting errors between their systems. This manual process can incur a great expense and result in the inconsistent member experience existing for long periods of time.

“Moreover, when a Claim Processing Vendor successfully processes a claim from a healthcare provider and wants to provide some of that information to a Recipient Claim Processing Vendor, it needs to do so in a format that meets the Recipient Claim Processing Vendor’s requirements. For each claim, individual eligibility, group information and service eligibility must be provided in the proper format to be utilized by the Recipient Claim Processing Vendor. Charge reversals, partial adjustments, deductibles, copays and the like complicate the process. If all Claim Processing Vendors working for a Healthcare Risk Bearer (with respect to the same individuals) do not get the same eligibility data and claim payment information, errors can occur regarding, for example, eligibility and payment amounts. Many Claim Processing Vendors have not established communication links with other Claim Processing Vendors. Software and hardware incompatibility are the usual impediment. Confidentiality is also a widespread concern.

“Accordingly, a need exist for systems and methods that can automatically reconcile claim posting errors between their systems and that can establish communication links between Claim Processing Vendors such that data integration may occur by transforming the data into a format that the Claim Processing Vendor and/or Recipient Claim Processing Vendor requires.”

In addition to the background information obtained for this patent, NewsRx journalists also obtained the inventors’ summary information for this patent: “In one embodiment, a computer machine system including one or more computer machines further includes at least one first computer memory having a first database and a second database. The first database is configured to store a plurality of eligibility data for a plurality of individuals associated a group healthcare plan, a set of user identifiers, wherein each user identifier is associated with a specific user, one or more demographic information from the specific user, and one or more eligibility data from said plurality of eligibility data. The second database is configured to store a plurality of rules for a claim submission associated with each group healthcare plan, a plurality of originating payors associated with the claim submission, each of the plurality of originating payors having at least one data submission requirements associated with the claim submission, and a plurality of rules for a processed claim submission associated with each of the plurality of originating payors. The plurality of originating payors transmit the plurality of eligibility data for the plurality of individuals associated with the group healthcare plan such that the at least one data submission requirement for each one of the plurality of originating payors is mapped to the database.

“In another embodiment, a computer machine implemented automated claim processing method includes the steps of receiving, from at least one of a plurality of recipient payors, a members demographic information from a plurality of individuals associated a group healthcare plan, storing the members demographic information onto a first database, extracting from the stored demographic information, a plurality of required information for a claim submission to each of the plurality of recipient payors on a second database, mapping a received claim in the first database using the required information for the claim submission for each one of the plurality of recipient payors, and communicating to each one of the plurality of recipient payors the mapped information.”

The claims supplied by the inventors are:

“1. A computer machine system having one or more computer machines wherein said computer machine system comprises: one or more processors; at least one first computer non-transitory, processor-readable storage medium having one or more programming instructions thereon, the at least one first computer storage medium configured to store: a plurality of eligibility data for a plurality of individuals associated with a group healthcare plan in a first data format; a set of user identifiers, wherein each user identifier is associated with: a specific user; one or more demographic information from the specific user; and one or more individual eligibility data from said plurality of eligibility data; and at least one second computer non-transitory, processor-readable storage medium having one or more programming instructions thereon, the at least one second computer storage medium configured to store: a first plurality of rules for a claim submission associated with each group healthcare plan, the first plurality of rules include instructions for translating the first data format to the claim submission for at least one of a plurality of originating payors associated with the claim submission and into a second data format and for translating in reverse into an original data format; a second plurality of rules for a processed claim submission associated with each of the plurality of originating payors, the second plurality of rules includes instructions for translating the second data format into a third data format for the processed claim submission for a plurality of recipient payors associated with the processed claim submission and for translating in reverse from the third data format into the second data format, wherein each of the plurality of recipient payors having at least one second data submission requirement associated with the processed claim submission for the plurality of recipient payors such that the third data format conforms to the at least one second data submission requirement, the third data format being different from the second data format, wherein the one or more programming instructions of the at least one first computer storage medium or the at least one second computer storage medium, when executed, cause the one or more processors to: translate automatically the first data format using the first plurality of rules, translate automatically the first data format into the second data format using the first plurality of rules for the processed claim submission associated with each one of the plurality of recipient payors, and translate automatically the second data format and the third data format using the second plurality of rules and the first plurality of rules in reverse into the original data format such that the original data format is mapped to the at least one first computer storage medium to notify the group healthcare plan of an outcome of the claim submission.

“2. The computer machine system of claim 1, wherein the first plurality of rules associated with the claim submission include a data format, a plurality of coding standards, a plurality of connectivity information, and a manner in which the claim submission is forwarded to the plurality of recipient payors.

“3. The computer machine system of claim 1, wherein each one of the claim submissions is forwarded to the plurality of recipient payors based on the first plurality of rules for each one of the claim submissions associated with each group healthcare plan.

“4. The computer machine system of claim 3, wherein each one of the claim submissions by the plurality of originating payors is posted in the second computer storage medium.

“5. The computer machine system of claim 4, wherein each one of the processed claim submissions that meets the at least one second data submission requirement associated with the processed claim submission for the plurality of recipient payors are released for transmission to the plurality of recipient payors.

“6. The computer machine system of claim 4, wherein each one of the processed claim submissions that fails to meet the at least one second data submission requirement associated with the processed claim submission for the plurality of recipient payors are held from transmission to the plurality of recipient payors until sufficient data is received such that the processed claim submissions meet the at least one second data submission requirement for the plurality of recipient payors.

“7. The computer machine system of claim 6, wherein the system continuously searches for missing data for each one of the processed claim submissions that are held from transmission to the plurality of recipient payors until sufficient data is received such that the processed claim submissions meets the at least one second data submission requirement for the plurality of recipient payors.

“8. The computer machine system of claim 1, further comprising: the at least one second computer storage medium configured to store: a third plurality of rules, the third plurality of rules associated with the processed claim submission for each one of the plurality of recipient payors, the third plurality of rules includes a plurality of full claim reversal rules and a plurality of partial adjustment rules specific to each one of the plurality of recipient payors.

“9. The computer machine system of claim 8, wherein the system generates a reference number specific to at least one of the plurality of recipient payors upon a full claim reversal of the processed claim submission that meets the plurality of full claim reversal rules.

“10. The computer machine system of claim 9, wherein a partial adjustment to the processed claim submission utilizes a chain of adjustment claims such that the partial adjustment is made when the partial adjustment with the chain of adjustment claims meets a plurality of partial adjustment rules.

“11. The computer machine system of claim 1, wherein the one or more computer machines is configured to integrate a plurality of co-pays and a plurality of deductibles based on the plurality of eligibility data for the plurality of individuals associated with the group healthcare plan and the set of user identifiers.”

There are additional claims. Please visit full patent to read further.

URL and more information on this patent, see: Eggertsen, John. Systems and methods of processing and reconciling healthcare related claims. U.S. Patent Number 11217346, filed October 17, 2018, and published online on January 4, 2022. 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=11217346.PN.&OS=PN/11217346RS=PN/11217346

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