“Systems For Reimbursing And Reconciling Pharamacy-Related Transactions” in Patent Application Approval Process (USPTO 20240095726): Truveris Inc.

2024 APR 08 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- A patent application by the inventors Janin, Bertrand (West Orange, NJ, US); Loiacono, Anthony Joseph (Bayonne, NJ, US), filed on November 28, 2023, was made available online on March 21, 2024, according to news reporting originating from Washington, D.C., by NewsRx correspondents.

This patent application is assigned to Truveris Inc. (New York, New York, United States).

The following quote was obtained by the news editors from the background information supplied by the inventors: “In general, patients can fulfill medical prescriptions at retail pharmacies. For example, a patient can obtain a prescription for a particular medication from his physician, and submit that prescription to a pharmacy for fulfillment. The pharmacy can validate the prescription with the physician and dispense the medication to the patient.

“In many cases, patients are medically insured, and the cost of their prescribed medications may be covered, at least in part, by their medical insurance policies. To facilitate the fulfillment of prescriptions, a retail pharmacy will often submit insurance claims on behalf of the patient to a payer associated with the insurance policy (e.g., a self-insured corporation, union, government entity, or health insurance carrier). For example, a retail pharmacy can obtain information regarding a patient’s medical insurance, and sell the prescribed medication to the patient at a subsidized rate (e.g., a retail or pre-determined price of the medication, less an amount to be covered by the patient’s insurance policy). The pharmacy reports the transaction to a payer associated with the insurance policy, and later receives reimbursement for the subsidized cost.

“In many cases, a pharmacy benefit manager (PBM) can act as a financial intermediary between several retail pharmacies and payers. For example, a PBM can collect numerous transactions from several pharmacies, then submit a consolidated set of transactions to each corresponding payer. In turn, each payer reimburses the PBM for the consolidated transactions, and the PBM redistributes the reimbursement to each corresponding pharmacy.

“In many cases, however, the process of consolidating transactions by a PBM, processing the consolidated transactions by the payer, reimbursing the PBM, and redistributing reimbursements to pharmacies can be a lengthy and opaque process. As such, there may be a substantial amount of time between when a pharmacy sells a medication at a subsidized cost and when the pharmacy is ultimately reimbursed for the sale. Thus, pharmacies would greatly benefit from a process capable of validating prescription transactions and reimbursing payments in an open, timely, and efficient manner.”

In addition to the background information obtained for this patent application, NewsRx journalists also obtained the inventors’ summary information for this patent application: “In general, in an aspect, a method of reimbursing pharmacy-related transactions includes receiving, at a computer system, first data describing a transaction between a patient and a pharmacy. The transaction includes dispensing of a medication. A reimbursement data packet is determined at the computer system based on the first data. The reimbursement data packet includes second data describing a reimbursement claim to be submitted to a payer for the transaction. The reimbursement data packet is transmitted from the computer system via a computer network to a plurality of other computer systems. A response is received via the computer network from each of the other computer systems. Each response indicates whether a respective one of the other computer systems determined that the reimbursement claim is valid. A determination is made at the computer system that the reimbursement claim is valid based on the responses. An entry describing the transaction and reimbursement claim is added to a ledger, and the reimbursement claim is submitted over the computer network for fulfillment.

“Implementations of this aspect may include or more of the following features.

“In some implementations, the method can further include transmitting at least a portion of the ledger to one or more of the other computer systems. The method can also further include cryptographically signing the portion of the ledger prior to transmitting the portion of the ledger to the one or more of the other computer systems. The portion of the ledger can include the entry describing the transaction and reimbursement claim.

“In some implementations, the reimbursement claim can be submitted to the payer for fulfillment.

“In some implementations, the reimbursement claim can be submitted to a broker for fulfillment by the payer.

“In some implementations, the medication can be a prescription medication.

“In some implementations, the ledger can be stored on the computer system.

“In general, in another aspect, a system for reimbursing pharmacy-related transactions includes a first computer system, and one or more other computer systems communicatively coupled to the first computer system via a computer network. The first computer system is configured to receive first data describing a transaction between a patient and a pharmacy. The transaction includes dispensing of a medication. The first computer system is also configured to determine a reimbursement data packet based on the first data. The reimbursement data packet includes second data describing a reimbursement claim to be submitted to a payer for the transaction. The first computer system is also configured to transmit, via the computer network, the reimbursement data packet to the one or more other computer systems, and receive, via the computer network, a response from the one or more other computer systems. Each response indicates whether a respective one of the other computer systems determined that the reimbursement claim is valid. The first computer system is also configured to determine that the reimbursement claim is valid based on the responses, add an entry describing the transaction and reimbursement claim to a ledger, and submit, over the computer network, the reimbursement claim for fulfillment.

“Implementations of this aspect may include or more of the following features.

“In some implementations, the first computer system can be further configured to transmit at least a portion of the ledger to one or more of the other computer systems. The first computer system also can be configured to cryptographically sign the portion of the ledger prior to transmitting the portion of the ledger to the one or more of the other computer systems. The portion of the ledger can include the entry describing the transaction and reimbursement claim.

“In some implementations, the first computer system can be configured to submit the reimbursement claim to the payer for fulfillment.

“In some implementations, the first computer system can be configured to submit the reimbursement claim to a broker for fulfillment by the payer.

“In some implementations, the medication can be a prescription medication.

“In some implementations, the ledger can be stored on the first computer system.

“One or more of the implementations described herein can provide various benefits. For instance, one or more implementations address various technical issues arising in the context of a computer-based system. As an example, as the validation process is distributed across multiple different entities, the validation and reimbursement process is more transparent and understandable to each of the entities. For instance, each pharmacy has access to the criteria by which reimbursement claims are validated, and can itself validate reimbursement claims made by others using the same criteria. Further, as each entity maintains a ledger of each of the reimbursement transactions performed on the system, each entity independently is able to analyze the reimbursement activity of others. This is beneficial, for example, as it can reduce the amount of fraud, unfair practices, or uncompetitive behavior between each of the parties (which might otherwise be hidden from scrutiny).

“Further, as each of the reimbursement claims is validated in a substantially automated manner, the reimbursement process can be performed relatively quickly (e.g., on the order of seconds, minutes, or hours). Thus, the parties can reconcile their transactions and/or receive reimbursements quickly and efficiently.

“Further, as the reimbursement process is distributed across multiple different computing systems (e.g., across multiple computing systems operated by multiple different pharmacies, PBMs, payers, and/or brokers), the system is highly decentralized. As such, the system is less susceptible to localized points of failure (e.g., failures of an isolated number of computer systems or the network connectivity between them), and is more likely to remain functional despite adverse conditions. Similarly, as a copy of the ledger is maintained across multiple computing systems, the need to backup individual computing systems is reduced, as the system can continue to function even when one or more individual computing systems are disrupted.

“Further, entities can freely join and leave the reimbursement system (e.g., by joining as additional “nodes” in the system to validate reimbursement claims and submit their own reimbursement). Thus, the system is highly flexible and scalable, and can readily accommodate any number of participants, and any combination of participants.

“Further still, the system enables users to exchange information in a secure manner (e.g., via encrypted transmissions between computing systems), such that sensitive data (e.g., financial or medication information) is less likely to be intercepted by unauthorized parties. Similarly, the system also enables users to exchange money in a secure manner, such that money is less likely to be stolen or misrouted by unauthorized parties.

“Further still, the system can be implemented over a variety of different computing networks, including the Internet. Thus, in some cases, the system can be deployed, maintained, and expanded without significant additional infrastructure.

“Further still, the system enables its users to collect longitudinal data regarding one or more entities associated with the system. For instance, as implementations of the system maintain complete (or substantially complete) records of the transactions conducted using the system, users of the system can collect and analyze data to determine overall market trends (e.g., overall prescription trends of doctors, overall market share of pharmacies, overall patient health for a population, and so forth), as well as individualized trends (e.g., the prescription trends of individual doctors, the market share of particular pharmacies, the medical histories of specific patients, and so forth).

“In some cases, an employer can use the system to obtain information regarding each of its employees. This can be beneficial, for example, as it allows the employer to better understand the health of its employees. Further, it also allows employers to quickly and efficiently obtain information regarding new employees (e.g., new hires), and understand each new employee’s impact on the employer’s medical benefits policies.

“The details of one or more embodiments are set forth in the accompanying drawings and the description below. Other features and advantages will be apparent from the description and drawings, and from the claims.”

The claims supplied by the inventors are:

“1. A decentralized method of initiating reimbursement of pharmacy-related transactions, the method comprising: receiving first supply data about a supply transaction between a first wholesaler and a first pharmacy, wherein the supply transaction comprises supplying a medication by the first wholesaler to the first pharmacy; generating a wholesaler reimbursement data packet based on the first supply data, wherein the wholesaler reimbursement data packet comprises second supply data about a wholesaler reimbursement claim, the second supply data including a quantity of the medication for the first pharmacy and a requested wholesaler reimbursement amount for the wholesaler reimbursement claim; transmitting the wholesaler reimbursement data packet to a plurality of second wholesaler computer systems of a plurality of second wholesalers outside of the supply transaction and listed in a wholesaler directory; receiving a wholesaler response from each second wholesaler computer system of the plurality of second wholesaler computer systems, wherein each wholesaler response indicates whether a respective one of the plurality of second wholesaler computer systems determined that the wholesaler reimbursement claim is valid, the wholesaler response of each second wholesaler computer system of the plurality of second wholesaler computer systems being determined based on a wholesaler condition involving the quantity of the medication and on the requested wholesaler reimbursement amount for the wholesaler reimbursement claim; determining that the wholesaler reimbursement claim is validated based on the wholesaler responses from the plurality of second wholesaler computer systems; adding an immutable wholesaler entry about the supply transaction and the wholesaler reimbursement claim to a first electronic ledger, the immutable wholesaler entry being cryptographically signed; transmitting, after adding the immutable wholesaler entry about the supply transaction and the wholesaler reimbursement claim to the first electronic ledger, at least a portion of the first electronic ledger that includes the immutable wholesaler entry to each second wholesaler computer system of the plurality of second wholesaler computer systems; receiving, at a first pharmacy computer system associated with the first pharmacy, first pharmacy data about a pharmacy transaction between a patient and the first pharmacy, wherein the pharmacy transaction comprises dispensing of the medication by the first pharmacy to the patient; generating, at the first pharmacy computer system, a pharmacy reimbursement data packet based on the first pharmacy data, wherein the pharmacy reimbursement data packet comprises second pharmacy data about a pharmacy reimbursement claim associated with the pharmacy transaction, the second pharmacy data including a quantity of the medication dispensed by the first pharmacy to the patient and a requested pharmacy reimbursement amount for the pharmacy reimbursement claim; transmitting, via a computer network, the pharmacy reimbursement data packet from the first pharmacy computer system to a second payer computer system associated with a second payer and to a plurality of second pharmacy computer systems of a plurality of second pharmacies outside of the transaction and listed in a pharmacy directory; receiving, via the computer network, a pharmacy response from each second pharmacy computer system of the plurality of second pharmacy computer systems, wherein each pharmacy response indicates whether a respective one of the plurality of second pharmacy computer systems determined that the pharmacy reimbursement claim is valid, the pharmacy response of each second pharmacy computer system of the plurality of second pharmacy computer systems being determined based on a pharmacy condition involving the quantity of the medication and on the requested pharmacy reimbursement amount for the pharmacy reimbursement claim; determining that the pharmacy reimbursement claim is validated based on the pharmacy responses from the plurality of second pharmacy computer systems; adding an immutable pharmacy entry about the pharmacy transaction and the pharmacy reimbursement claim to a pharmacy electronic ledger, the pharmacy electronic ledger being stored by the first pharmacy computer system, the immutable pharmacy entry being cryptographically signed by the first pharmacy computer system; and transmitting, after adding the immutable pharmacy entry about the pharmacy transaction and the pharmacy reimbursement claim to the pharmacy electronic ledger, at least a portion of the pharmacy electronic ledger that includes the immutable pharmacy entry to the second payer computer system, the validated pharmacy reimbursement claim contained in the at least a portion of the pharmacy electronic ledger and the validated wholesaler reimbursement claim contained in the at least a portion of the first electronic ledger causing the second payer computer system to initiate processing of the pharmacy reimbursement claim and a first payer system to initiate processing of the wholesaler reimbursement claim.

“2. The method of claim 1, wherein the receiving the pharmacy response from each second pharmacy computer system of the plurality of second pharmacy computer systems comprises receiving the pharmacy response from each of a selected subset of the second pharmacy computer systems listed in the pharmacy directory.

“3. The method of claim 1, wherein the pharmacy condition involves a determination whether the requested pharmacy reimbursement amount is reasonable relative to the quantity of the medication.

“4. The method of claim 1, wherein the pharmacy condition involves a determination whether the quantity of the medication is within reasonable limits.

“5. The method of claim 1, wherein the pharmacy condition involves a determination whether the medication is normally prescribed by doctors.

“6. The method of claim 1, wherein the pharmacy condition involves a determination whether a historical amount of the medication being dispensed by the first pharmacy is within an expected range, the expected range being calculated from an analysis of transactions on the pharmacy electronic ledger.

“7. The method of claim 1, wherein the plurality of second pharmacy computer systems includes all of the second pharmacy computer systems associated with a pharmacy listed in the pharmacy directory.

“8. The method of claim 7, wherein the pharmacy directory can be modified to add or remove particular second pharmacy computer systems.”

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

URL and more information on this patent application, see: Janin, Bertrand; Loiacono, Anthony Joseph. Systems For Reimbursing And Reconciling Pharamacy-Related Transactions. U.S. Patent Application Number 20240095726, filed November 28, 2023 and posted March 21, 2024. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(20240095726)&db=US-PGPUB&type=ids

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