“System And Method For Billing Healthcare Services” in Patent Application Approval Process (USPTO 20190139012)

2019 MAY 28 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- A patent application by the inventors Kube, II, Richard A. (Peoria, IL); Ingraham, Colleen (Peoria, IL), filed on August 16, 2018, was made available online on May 9, 2019, according to news reporting originating from Washington, D.C., by NewsRx correspondents.

This patent application is assigned to Prairie Spine and Pain Institute (Peoria, Illinois, United States).

The following quote was obtained by the news editors from the background information supplied by the inventors: “In most markets, prices and quality indicators are transparent--clear and readily available to consumers. Health care is different. For healthcare, prices are difficult to obtain and are often meaningless when they are disclosed. Patients who ask for price information from a healthcare service provider are likely to receive little or no information. Typically, neither a hospital nor a doctor will know the cost until the procedure is completed. It is generally recognized that the U.S. healthcare system makes it difficult to find information on quality and cost of care. This hidden information is putting patients at risk. This secrecy puts everyone from consumers to corporations at an unfair disadvantage--leading to gaps in quality of care and much higher costs.

“The healthcare industry historically has used a variety of medical codes to document and bill for healthcare services and supplies. Recently, a variety of payors and providers in the healthcare industry have proposed a bundled payment model, or ‘global fee model,’ in an attempt to improve price transparency. The global fee model combines all fees for healthcare services into a single fee. For example, services provided by surgeons, surgical assists, anesthesiologists, certified registered nurse anesthetists, radiology/imaging, pathology, implants, disposables, hospitals and facilities are to be combined into a single fee under the global fee model.

“The global fee model presently does not exist outside of the hospital setting. For non-hospital healthcare providers, conventional medical billing systems either (1) use a generic and pre-determined written description of the medical procedure or (2) expand the meaning of an existing medical billing code to generate an invoice.

“These current medical billing systems have deficiencies. In scenario (1), no way presently exists for the medical billing system to integrate the description of the medical procedure into the healthcare provider’s practice management system. Consequently, it is inefficient and time consuming (i) to create an invoice and/or, (ii) to manage and track payments and adjustments, etc., based upon generic boilerplate written descriptions of medical procedures that are pre-installed into conventional medical billing systems. This scenario (1) would require tracking to occur outside of the existing practice management systems.

“Current medical record/billing systems rely upon the condition that one and only one meaning is applicable for a given individual medical billing code. To expand the meaning for a code to mean something more than its original definition creates problems. In scenario (2), expanding the definition of existing medical billing codes creates confusion and likelihood for human error. For example, no rule or formula exists in current healthcare practice management systems to determine when to use a given CPT definition. A user (a healthcare provider or a payor, for example) of an incumbent medical record/billing system must choose, on a case-by-case basis whether to use the traditional definition of an AMA CPT code or whether to use an expanded definition for a given CPT code. This introduces uncertainty into the medical billing cycle because healthcare employees not trained in medical billing are called to make billing/charge decisions beyond their skill sets--leading to confusion and ambiguity. Scenario (2) also eliminates the healthcare provider’s ability to have a universal charge master for each medical billing code. Since a given medical billing code can often mean different things in Scenario (2), the same medical billing code oftentimes carries different fees under different situations, causing even more confusion. The uncertainty under Scenario (2) exposes a healthcare provider to the risk of being accused as having a fluid charge master, which could be construed as a violation of standard medical services payor contracts, such as contracts with Medicare and Medicaid.

“A need exists for a healthcare billing methodology that converts the descriptions of bundled services into a code that readily translates into language used in existing practice management software. A need further exists for healthcare billing methodology that gives each medical billing code a distinct and constant definition allowing for a universal charge master, and for revenue cycle management staff to implement the same into their existing medical billing systems with minimal training and virtually no change in workflows.”

In addition to the background information obtained for this patent application, NewsRx journalists also obtained the inventors’ summary information for this patent application: “The present disclosure provides a system. In an embodiment, a system for billing healthcare services is provided and includes one or more computing devices. The one or more computing devices include a memory module, an interface, and a processing module. The processing module includes a billing module and an integration module. The memory module stores (i) patient historical data, (ii) a universal charge master database, (iii) a medical billing code database, (iv) a payor fee schedule database, and (v) an entire health encounter (EHE) database. The EHE database includes a unique identifier for each EHE. For each EHE, the unique identifier includes a custom code, a procedure name, a description of EHE services, a list of EHE-related medical billing codes, and a contract rate for the EHE. Receipt of the custom code by the billing module triggers the integration module to perform the following functions: (vi) calculate a universal charge rate for the EHE based on the EHE-related medical billing codes and the universal charge master; (vii) attach the custom code to the contract rate for a specified payor; (viii) apply a discount for the difference between the universal charge rate and the contract rate; and (ix) generate a bill for healthcare services for the specified payor. The bill has a 1-line entry with the custom code, the procedure name, and the contract rate.

“The present disclosure provides a method. In an embodiment, a method for billing healthcare services is provided and includes preparing a list of medical procedures necessary for providing an entire healthcare encounter (EHE) to a patient. The method includes linking the EHE with two or more relevant medical billing codes. The method includes determining a contract rate for the EHE. The method includes creating a unique identifier for the EHE. The unique identifier includes (i) a custom code, (ii) a procedure name, (iii) a description of EHE services, (iv) a list of EHE-related medical billing codes, and (v) the contract rate for the EHE. The method includes calculating a universal charge for the EHE from a universal charge master and from the EHE-related CMS codes. The method includes attaching the custom code to the contract rate for a specified payor. The method includes applying a discount for the difference between the universal charge rate and the contract rate. The method includes generating a bill for healthcare services for the specified payor. The bill has a 1-line entry with the custom code, the procedure name, and the contract rate.”

The claims supplied by the inventors are:

“1. A system for billing healthcare services comprising: one or more computing devices comprising a memory module, an interface, and a processing module comprising a billing module and an integration module; the memory module storing (i) patient historical data; (ii) a universal charge master database; (iii) a medical billing code database; (iv) a payor fee schedule database; and (v) an entire health encounter (EHE) database, the EHE database comprising a unique identifier for each EHE, the unique identifier comprising a custom code, a procedure name, a description of EHE services, a list of EHE-related medical billing codes; and a contract rate for the EHE; wherein receipt of the custom code by the billing module triggers the integration module to calculate a universal charge rate for the EHE based on the EHE-related medical billing codes and the universal charge master; attach the custom code to contract rate for a specified payor; apply a discount for the difference between the universal charge rate and the contract rate; and generate a bill for healthcare service for the specified payor, the bill comprising a 1-line entry with the custom code, the procedure name, and the contract rate.

“2. The system of claim 1 wherein the integration module stores the discount in the memory module.

“3. A method for billing healthcare services comprising: preparing a list of medical procedures necessary for providing an entire healthcare encounter (EHE) to a patient; linking the EHE with two or more relevant medical billing codes; determining a contract rate for the EHE; creating a unique identifier for the EHE, the unique identifier comprising (i) a custom code, (ii) a procedure name, (iii) a description of EHE services, (iv) a list of EHE-related medical billing codes; and (v) the contract rate for the EHE; calculating a universal charge rate for the EHE from a universal charge master and the EHE-related CMS codes; attaching the custom code to the contract rate for a specified payor; applying a discount for the difference between the universal charge rate and the contract rate; and generating a bill for healthcare services for the specified payor, the bill comprising a 1-line entry with the custom code, the procedure name, and the contract rate.

“4. The method of claim 3 comprising recording the universal charge, the discount, and contract rate for the FHF.”

URL and more information on this patent application, see: Kube, II, Richard A.; Ingraham, Colleen. System And Method For Billing Healthcare Services. Filed August 16, 2018 and posted May 9, 2019. 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=%2220190139012%22.PGNR.&OS=DN/20190139012&RS=DN/20190139012

(Our reports deliver fact-based news of research and discoveries from around the world.)