Dynamic topological system and method for efficient claims processing

#The disclosure relates generally to a system and method for healthcare claims processing and in particular to a dynamic topological system and method for efficient claims processing.

#A healthcare marketplace system may provide a transparent health services marketplace with clear descriptions and posted prices. Many health care providers and payers use legacy systems to communicate information to the healthcare marketplace system for a variety of transactions: eligibility checks, claims processing and benefits enrollment. To integrate the healthcare marketplace system capabilities with existing systems in the health care space, it's important that it be able to process massive streams of transactional data related to health care services. The ability to process these transaction streams enables: real-time eligibility checks for quote requests, submitting a claim for a service after paying cash so that the service cost can contribute toward a deductible, and enrolling a consumer in new health benefits so that they might save money on expensive services. Integrating all of these transaction capabilities with the health service marketplace provides consumers with easy access to information to help them make informed decisions concerning their health care spending. It also provides health care providers and payers with more efficiencies so that administrative costs for processing health care transactions approach zero. Without the dynamic transactional data streaming capabilities, consumers would only be able to use the healthcare marketplace system for cash based transactions and would have to consult other systems for insurance based pricing. The dynamic transactional data streaming may provide the best possible user experience for health care consumers and providers participating in the health care services marketplace.

#Since many healthcare providers and payers use legacy systems to communicate information for a variety of transactions (eligibility checks, claims processing and benefits enrollment), according to the American Medical Association (“AMA”), administrative costs associated with the processing of health care insurance claims is upwards of $210 billion per year in the United States. The AMA also estimates that as many as 1 in 5 claims is processed inaccurately leading to significant amounts of money lost due to waste, fraud, and abuse. Thus being able to accurately predict whether a claim will be denied before it is submitted to the payer as well as predicting if the claim was accurately paid after adjudication has the potential greatly improve provider's revenue cycle management.

#FIG. 1 illustrates a health care marketplace system that may incorporate a dynamic topological component for claims processing;

#FIG. 2 illustrates more details of the claims processing component;

#FIG. 3 illustrates a method for claims processing that may be implemented using the claims processing component;

#The disclosure is particularly applicable to a claims processing system incorporated into a health system as described below and it is in this context that the disclosure will be described. It will be appreciated, however, that the system and method has greater utility since it may be implemented in other manners that those disclosed below and may be a standalone claims processing system as well as software as a service (SaaS) system that provides claims processing to a plurality of third party systems.

#A healthcare marketplace system may include one or more payers of healthcare services and products, one or more healthcare service and product providers and one or more consumers of the healthcare services or products. To reduce costs for the payer, provider and consumer, a claims processing system described below provides a modeling process that will enable more efficient claims processing for medical services as described below in more detail.

#FIG. 1 illustrates an example of a health network system 100 that may incorporate a claims processing component 113. In the example in FIG. 1, the system may be implemented as a client/server, software as a service (SaaS) or a cloud based architecture. However, the system and in particular the claims processing component 113 may also be implemented on a standalone computer system that performs the operations of the claims processing component 113 as described below or the claims processing component 113 may be integrated into other systems.