Researchers Submit Patent Application, “Health Insurance Claim Coding System”, for Approval (USPTO 20200043099)

2020 FEB 26 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- From Washington, D.C., NewsRx journalists report that a patent application by the inventors Thakkar, Vatsal Girish (New York, NY); Brown, William L. (New York, NY), filed on July 31, 2019, was made available online on February 6, 2020.

No assignee for this patent application has been made.

News editors obtained the following quote from the background information supplied by the inventors: “The CMS-1500 is the standard health insurance claim form and is the foundation upon which all health insurance claims for both public and private insurance plans are based. The current CMS-1500, OMB #0938-1197, is a one-page document that consists of thirty-three item categories that comprise 232 individual fields of data entry. The electronic version of this claim form is the 837 Professional (837P) and is considered equivalent to and synonymous with the CMS-1500.

“The CMS-1500 brings together data elements from at least three separate health care entities involved in the transaction for which the claim is being submitted. These three entities are the health insurance payer, the healthcare service provider/vendor, and the transaction’s consumer, typically identified as the patient.

“The basic provider and practice/organization information, which typically remains the same for all healthcare claims for that provider/organization, corresponds to the following fields on the CMS-1500: 24B, 24J, 25, 27,32, 32a, 33, 33a.

“The healthcare service provider/vendor specifies further data elements necessary for the CMS-1500 in the form of the International Classification of Diseases, 10th Revision codes (abbreviated as ‘ICD-10’ codes, also known as ‘diagnosis’ or ‘dx’ codes) and Current Procedural Terminology codes (abbreviated as ‘CPT’ codes, also known as ‘procedure’ or ‘service’ codes), and the fees for each of the CPT codes, along with other bits of data. These data elements do not vary significantly for any given provider or entity, based on their specialty. For example, in his/her career, a physician may only utilize 30-40 diagnosis codes (of the tens of thousands available), 5-10 CPT codes (of the thousands available), and may only have five different fees based on his/her practice type and setting. The corresponding fields on the CMS-1500 claim form are 21, 24D, 24E, 24F, and 24G.

“The final bits of data are provided by the patient and the primary insured for the health insurance policy. This data includes the names, demographic information (address, date of birth, etc.), along with the type of insurance policy, ID number, etc. The corresponding fields on the CMS-1500 are fields 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 (all fields between 1-13).

“The current NPI (National Provider Identifier) system, which is designed, executed, and maintained by the United States Department of Health and Human Services is limited for purposes of providing a ten-digit code for health insurance claim processing. While the NPI database does identify almost all of the millions of individual health care providers as well as the millions of healthcare organizations in the United States, it does not accomplish the following, which are necessary features to complete a health insurance claim. First, the NPI database does not make available a provider’s or organization’s Taxpayer Identification Number (or Employer Identification Number, EIN). Further, the NPI database does not link individual practitioners and the NPI numbers with practices, hospitals, and/or healthcare organizations which have their own, distinct NPI numbers (defined in the NPI system as a Type II NPI number). The NPI information for both the provider and the organization needs to be included on a health insurance claim. Also, the NPI database identifies the provider’s specialty (defined as ‘taxonomy’), but does not offer a compendium of the providers more frequently used ICD-10 codes, CPT codes, or fees.

“There does not exist today a systematic, streamlined means of clustering these claim data elements together for repeated use for the purposes of enhanced efficiency, faster claim filing and processing, error reduction, and facilitation for any party in the healthcare transaction to initiate a health insurance claim.”

As a supplement to the background information on this patent application, NewsRx correspondents also obtained the inventors’ summary information for this patent application: “This summary is provided to introduce a variety of concepts in a simplified form that is further disclosed in the detailed description of the embodiments. This summary is not intended to identify key or essential inventive concepts of the claimed subject matter, nor is it intended for determining the scope of the claimed subject matter.

“The embodiments disclosed herein provide a rapid and high-fidelity health insurance coding system comprising a network and a database in communication with the network to store patient data and medical practitioner data. A provider terminal is utilized by the medical practitioner to input a plurality of codes, each corresponding to a patient visit. A medical insurance claim processing engine receives the codes and automatically generates a medical insurance claim form from at least one of the plurality of codes. The medical insurance claim form is then transmitted via the network to an insurance payer. The embodiments provide a systematic and streamlined means for gathering claim data elements for repeated use. This system enhances efficiency, reduces errors, and facilitates communication between multiple healthcare parties.

“In one aspect, the medical insurance claim processing engine receives at least one of the following: a service package name, one or more diagnostic codes, one or more CPT codes, and one or more fees for any given health care provider or facility.

“In one aspect, the fee is associated with the service package name.

“In one aspect, the medical practitioner or system administrator inputs a plurality of service package names each stored in the database.

“In one aspect, the medical practitioner or system administrator inputs a plurality of diagnostic codes, each corresponding to a patient diagnosis. The plurality of diagnostic codes is stored in the database.

“In one aspect, the code is customizable via the medical provider or system administrator to input codes most relevant to the provider’s area of medical practice.

“In one aspect, the network is accessible by one or more insurance payers, health care vendors, or other parties involved in the health care transaction.

“In one embodiment, the code can be auto-generated based on actual health insurance claims being filed in real-time on the network.

“In some embodiments, a method for generating a health insurance claim form is disclosed comprising the steps of inputting, via a medical practitioner utilizing a provider terminal, a plurality of codes corresponding to patient information. Next, an interpretation module interprets the plurality of codes which are then transmitted to a medical insurance claim processing engine which automatically generates a medical insurance claim form using the plurality of codes. The medical insurance claim form is then transmitted to an insurance payer.”

The claims supplied by the inventors are:

“1. A health insurance claim coding system, comprising: a network and a database in communication with the network to store patient data and medical practitioner data; a provider terminal utilized by the medical practitioner to input a plurality of diagnostic codes each corresponding to a patient visit; and a health insurance claim processing engine to receive the plurality of diagnostic codes and automatically generate a health insurance claim form from at least one of the plurality of codes, the health insurance claim form transmitted via the network to an insurance payer.

“2. The system of claim 1, wherein the health insurance claims processing engine receives at least one of the following: an exam name, one or more diagnostic codes, one or more CPT codes, and a fee.

“3. The system of claim 2, wherein the fee is associated with the exam name.

“4. The system of claim 1, wherein the medical practitioner inputs a plurality of exam names each stored in the database.

“5. The system of claim 4, wherein the medical practitioner inputs a plurality of diagnostic codes each corresponding to a patient diagnosis, and wherein the plurality of diagnostic codes are stored in the database.

“6. The system of claim 5, wherein each of the plurality of diagnostic codes is customizable via the medical provider.

“7. The system of claim 1, wherein the network is accessible by one or more insurance payers.

“8. A health insurance claim coding system, comprising: a network and a database in communication with the network to store patient data and medical practitioner data; a provider terminal utilized by the medical practitioner to input a plurality of codes each corresponding to a patient visit; an interpretation module to interpret the plurality of codes input by the medical practitioner; and a health insurance claim processing engine in communication with the interpretation module, the health insurance claims processing engine receives the plurality of diagnostic codes and automatically generates a health insurance claim form from at least one of the plurality of codes, the health insurance claim form transmitted via the network to an insurance payer.

“9. The system of claim 8, wherein the plurality of codes are transmitted to a QR code module to generate a QR code corresponding to the plurality of codes.

“10. The system of claim 9, wherein the interpretation module interprets the QR code and transmits the interpreted QR code to the health insurance claim processing engine.

“11. The system of claim 9, further comprising an optical character recognition module to interpret the plurality of codes.

“12. The system of claim 8, wherein the medical insurance claim processing engine receives at least one of the following: an exam name, one or more diagnostic codes, one or more CPT codes, and a fee.

“13. The system of claim 12, wherein the fee is associated with the exam name.

“14. The system of claim 8, wherein the medical practitioner inputs a plurality of exam names each stored in the database.

“15. The system of claim 14, wherein the medical practitioner inputs a plurality of diagnostic codes each corresponding to a patient diagnosis, and wherein the plurality of diagnostic codes are stored in the database.

“16. The system of claim 15, wherein each of the plurality of diagnostic codes is customizable via the medical provider.

“17. The system of claim 8, wherein the network is accessible by one or more insurance payers.

“18. A method for generating a health insurance claim form, the method comprising the steps of: inputting, via a medical practitioner utilizing a provider terminal, a plurality of codes corresponding to patient information; interpreting, via an interpretation module, the plurality of codes; transmitting the plurality of codes to a health insurance claim processing engine; receiving, via the health insurance claims processing engine, the interpreted codes and automatically generating a health insurance claim form using the plurality of codes; and transmitting, via a network, the health insurance claim form to an insurance payer.

“19. The method of claim 18, wherein the plurality of codes are transmitted to a QR code module to generate a QR code corresponding to the plurality of codes.

“20. The method of claim 19, wherein the interpretation module interprets the QR code and transmits the interpreted QR code to the health insurance claim processing engine.”

For additional information on this patent application, see: Thakkar, Vatsal Girish; Brown, William L. Health Insurance Claim Coding System. Filed July 31, 2019 and posted February 6, 2020. Patent URL: http://appft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PG01&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.html&r=1&f=G&l=50&s1=%2220200043099%22.PGNR.&OS=DN/20200043099&RS=DN/20200043099

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