Computer implemented methods and systems for bundled payment adjudication

A server system, comprising:

• a memory configured to store instructions;
• and
• a processor configured to execute the instructions stored in the memory and thereby cause the server system to perform:
• receiving patient information of a patient, the patient information comprising at least a patient identifier and a clinical episode associated with the patient;
• generating an episode card for the patient to avail health care services subsequently provided by one or more healthcare service providers for an eligibility period, the episode card comprising claims submission information for healthcare services availed by the patient subsequently provided by the one or more healthcare service providers;
• receiving one or more claims associated with the patient from at least one health care service provider of the one or more health care service providers, each claim being associated with one or more health care services availed by the patient in the predefined time for the clinical episode using the episode card, wherein the episode card is used in lieu of the patient's regular insurance card for the clinical episode;
• processing the one or more claims for determining validity of each claim of the one or more claims based on a comparison of the one or more health care services associated with each claim with a set of episode definition parameters, wherein the set of episode definition parameters is predefined for the clinical episode and comprises information of at least valid diagnoses of the clinical episode, the clinical episode start, the clinical episode length, and at least one valid health care service provider of the one or more health care service providers;
• and
• upon processing the one or more claims, facilitating a payment amount for the one or more claims of the at least one health care service provider based on the validity of the set of episode definition parameters;
• wherein for generating the episode card for the patient, the server system is further caused to perform at least:
• accessing eligibility information of the patient based on an eligibility file provided by an insurance service provider or an employer group, the eligibility file comprising health insurance details of the patient;
• determining an eligibility of the patient for a bundled payment of claims for the clinical episode based on the eligibility information;
• and
• upon determining the patient as an eligible candidate for the bundled payment of claims, calculating a patient responsibility and a total bundled claim for the clinical episode of the patient.

A method, comprising:

• receiving, by a processor, patient information of a patient, the patient information comprising at least a patient identifier, a clinical episode associated with the patient, and a primary health insurance information associated with the patient;
• accessing, by the processor, eligibility information of the patient based on an eligibility file provided by an insurance service provider or an employer group, the eligibility file comprising health insurance details of the patient;
• determining, by the processor, an eligibility of the patient for a bundled payment of claims for the clinical episode based on the eligibility information;
• upon determining the patient as an eligible candidate for the bundled payment of claims, generating, by the processor, an episode card for the patient to avail healthcare services subsequently provided by one or more healthcare service providers for an eligibility period, wherein the one or more healthcare service providers raise one or more claims for at least one health care service availed by the patient using the episode card, wherein the episode card is used in lieu of the patient's regular insurance card for the clinical episode;
• processing, by the processor, the one or more claims for determining validity of each claim of the one or more claims based on a comparison of the one or more health care services associated with each claim with a set of episode definition parameters, wherein the set of episode definition parameters is predefined for the clinical episode and comprises information of at least valid diagnoses of the clinical episode, the clinical episode start, the clinical episode length, and at least one valid health care service provider of the one or more health care service providers;
• upon processing the one or more claims, facilitating, by the processor, a payment amount for the one or more claims of the at least one health care service provider based on the validity of the set of episode definition parameters;
• wherein generating the episode card for the patient comprises:
• calculating, by the processor, a patient responsibility and a total bundled claim for the clinical episode of the patient based on the primary health insurance information;
• and
• wherein calculating the patient responsibility comprises:
• determining, by the processor, if a health plan scheme in the primary health insurance information is at least one of an employer group carve-out scheme or a health plan pay or scheme, wherein
• in the employer group carve-out scheme, the patient responsibility is determined based on the eligibility information;
• and
• in the health plan payor scheme, the patient responsibility is determined based on a financial information comprising a deductible amount, a copay amount, a coinsurance amount and an out of pocket (OOP) max amount accessed from the insurance service provider.