“System For Providing An Automated Electronic Healthcare Insurance Payor Platform” in Patent Application Approval Process (USPTO 20230289888): Patent Application

2023 SEP 28 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- A patent application by the inventor Bemis, Richard (Lakewood, CA, US), filed on March 8, 2023, was made available online on September 14, 2023, according to news reporting originating from Washington, D.C., by NewsRx correspondents.

This patent application has not been assigned to a company or institution.

The following quote was obtained by the news editors from the background information supplied by the inventors: “Healthcare payor business processes are complex and demanding. Regulatory requirements impact clinical and administrative processes used by multiple departments. Departments must manually re-classify data to process claims, manage provider directory, care delivery, utilization management, case management, benefit entitlements, open enrollment, and more. If not managed correctly, processing becomes error-prone and creates additional overhead and increases operational cost. Manual processes make it difficult to react to regulations, providers, members, and more. An efficient enterprise digital payor platform automates these processes and makes adapting to changing business and regulations easier.”

In addition to the background information obtained for this patent application, NewsRx journalists also obtained the inventor’s summary information for this patent application: “This summary is provided to introduce a variety of concepts in a simplified form that is disclosed further 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 herein relate a system that provides a platform for automating healthcare insurance administration. The system includes at least one user computing device in operable connection with a user network. An application server is in operable communication with the user network to host an application system for providing a platform for automating healthcare insurance administration. The application system includes a user interface for providing access to the application system through the user computing device. The system provides an automated healthcare insurance payor platform. The system allows for claims management integration, provider data management, provider relations, provider directory, contract management for physicians, nurses, surgical technicians, ancillary providers, member management, care delivery encounters, benefits entitlement, better healthcare customer support, and reduces corrective actions plans. The system may also provide better patient outcomes, more accurate healthcare case management, intelligent reporting to health care agencies, better sharing of healthcare pandemic information, and reduced overhead for operations.

“In the current arts, some limitations and disadvantages of current industry processes include; poor payment reconciliation, risk due to out of compliance provider directories, members traveling to the wrong address for care, time and distance standards are inaccurate, inaccurate information leading to grievances, inaccurate provider assignment to the patient, non-compliance in all aspects of payor administration, and increased member/provider support calls. The embodiments described herein relate to a system for providing a software platform for automating healthcare payor administration functions.

“The system reduces the cost to the consumer, payor, and facilitates improved processes for data management and reporting in the healthcare insurance industry. This includes provider-to-contract, member-to-benefits, encounter-to-claims, and case/utilization management transactions. The system is a centralized healthcare insurance payor platform, automated processing center, and centralized data repository platform for structured and unstructured healthcare data. This may include provider data management as a service (PDMaaS), member assignment to a primary care physician, facility site review, intelligent claims coding (ICC), and intelligent provider directory (IPD). The system may utilize artificial intelligence, machine learning, data mastering methods, workflow, structured data, semi-structured data, and big data management to provide an automated platform solution for the healthcare payor industry. For this document, payor and payer are used interchangeably.

“The drawings are not necessarily to scale, and certain features and certain views of the drawings may be shown exaggerated in scale or in schematic in the interest of clarity and conciseness.”

The claims supplied by the inventors are:

“1. A system for providing a platform for automating healthcare insurance administration, the system comprising: at least one user computing device in operable connection with a user network; and an application server in operable communication with the user network, the application server configured to host an application system for providing a platform for automating healthcare insurance administration, the application system having a user interface for providing access to the application system through the at least one user computing device.

“2. The system for providing a platform for automating healthcare insurance administration as in claim 1, wherein the application server is configured to host an application system for providing a platform that automates a payors transition from a fee-for-service to a value-based care while complying with regulatory changes effecting payor operations.

“3. The system for providing a platform for automating healthcare insurance administration as in claim 2, further comprising: a database for storing healthcare insurance information associated with at least one user, including at least one of claims, policies, or payment information, wherein the database is accessible by authorized healthcare providers and insurance companies for processing claims and payments.

“4. The system for providing a platform for automating healthcare insurance administration as in claim 3, comprising: a core enterprise system in operable communication with a user network, where the core enterprise system is configured to provide at least one of a multi-domain member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, claims MDM, or business rule handling.

“5. The system for providing a platform for automating healthcare insurance administration as in claim 1, comprising: a claims module configured to provide for paying and reconciling a provider and at least one member reimbursement for a paid claim.

“6. The system for providing a platform for automating healthcare insurance administration as in claim 1, comprising: a provider module configured to provide at least one of provider contracts management, provider network agreement management, provider data CRM workflow, credentialing CRM support, embedded or internal data capture, or facilities sites review.

“7. The system for providing a platform for automating healthcare insurance administration as in claim 1, comprising: a contract management module configured to provide at least one of contract management for physicians, nurses, surgical technicians, or ancillary providers.

“8. The system for providing a platform for automating healthcare insurance administration as in claim 1, comprising: a plan benefit administration module configured to provide at least one of plan products management, benefit management, plan reference code management, line of business plan management, or plan rate association development.

“9. The system for providing a platform for automating healthcare insurance administration as in claim 1, comprising: a member module configured to provide at least one of member support, eligibility and enrollment, assignment, call center workflow control, relationship management, customer relationship management, or workforce management.

“10. The system for providing a platform for automating healthcare insurance administration as in claim 1, comprising: an encounter module configured to provide at least one of EDI processing, provider processing, or encounter processing.

“11. A computer program product, comprising: an application server comprising a core enterprise system in operable communication with a user network; a claims module; a provider module; a contract management module; a plan benefit administration module; a member module; and an encounter module.

“12. The computer program product as in claim 11, wherein the application server is configured to host an application system for providing a platform that automates a payors transition from a fee-for-service to a value-based care while complying with regulatory changes effecting payor operations.

“13. The computer program product as in claim 11, further comprising: a database for storing healthcare insurance information associated with at least one user, including at least one of claims, policies, or payment information, wherein the database is accessible by authorized healthcare providers and insurance companies for processing claims and payments.

“14. The computer program product as in claim 11, wherein the core enterprise system is configured to provide at least one of a multi-domain member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, claims MDM, or business rule handling.

“15. A method of automating healthcare insurance administration, comprising: hosting an application system for providing a platform for automating healthcare insurance administration on a network, the application system comprising a core enterprise system configured to provide at least one of a multi-domain member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, claims MDM, or business rule handling; and providing access to the application system via a user interface accessible through at least one user computing device.

“16. The method of automating healthcare insurance administration, as in claim 15, wherein the application system is configured to host an application system for providing a platform that automates a payors transition from a fee-for-service to a value-based care while complying with regulatory changes effecting payor operations.

“17. The method of automating healthcare insurance administration, as in claim 15, wherein the application system is in operable communication with a database for storing healthcare insurance information associated with at least one user, including at least one of claims, policies, or payment information, wherein the database is accessible by authorized healthcare providers and insurance companies for the purpose of processing claims and payments.

“18. The method of automating healthcare insurance administration, as in claim 15, wherein the application system is in operable communication with a core enterprise system in operable communication with a user network, where the core enterprise system is configured to provide at least one of a multi-domain member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, claims MDM, or business rule handling.”

URL and more information on this patent application, see: Bemis, Richard. System For Providing An Automated Electronic Healthcare Insurance Payor Platform. U.S. Patent Application Number 20230289888, filed March 8, 2023 and posted September 14, 2023. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(20230289888)&db=US-PGPUB&type=ids

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