System and user interface supporting use of rules for processing healthcare and other claim data

#This invention concerns a system and user interface for use in determining, applying and managing rules in processing claim data for payment for provision of services to patients by a healthcare provider, for example.

#An important function performed by healthcare providers (such as hospitals, clinics or physicians) is the sending of claims to healthcare payer institutions to obtain reimbursement for provision of services to a patient. These claims may be in electronic or paper format. Paper claims typically go through a data entry process that converts them to an electronic format. The entered electronic claims are usually sorted, indexed and archived. Each claim is processed in a payer institution adjudication system. The payer adjudication system interprets the claim data and determines whether or not the claim is to be paid in full, partially paid or denied. This adjudication process may be fully automated, partially automated, or manual. The results of claim adjudication may include the issuance of a check and an explanation of benefits (EOB) to the insured and healthcare provider, or a request to send additional information. The process of reviewing claims is labor-intensive and error-prone.

#In known systems, healthcare claim payer organizations provide healthcare providers with definitions of rules that are to be applied by payers in adjudicating claims submitted by healthcare providers. This means healthcare providers locally re-create and implement their own rules (that ideally mirror the payer rules) for use in creating claims and for establishing admission and treatment procedures that provide information compatible with rule requirements. However, a healthcare provider needs to interpret the rule definitions provided by a payer organization in order to implement rules locally. Further, a healthcare provider also needs to implement and apply claim processing rules derived from other sources such as from Regulatory institutions (such as a CCI—correct coding initiative rule) and from the healthcare provider itself (e.g., a rule to write-off small outstanding balances).

#FIG. 1 shows an overall claim data processing system employing rules processing, according to invention principles.

#FIG. 2 shows a rules processing system used in the overall claim processing system of FIG. 1, according to invention principles

#FIG. 3 shows a flowchart of a process employed in rules processing by the systems of FIGS. 1 and 2, according to invention principles.

#FIG. 1 shows an overall claim processing system employing trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. In the FIG. 1 system, continuously updated centralized common rules in repository 74 are employed to ensure that individual healthcare providers, as well as individual healthcare payer institutions are working with the most up-to-date version of the rules. Use of centralized rules ensures that a healthcare provider is able to comply with the latest provisions of the rules. A rule as used herein comprises a procedure (including an executable procedure or a procedure implemented with manual intervention) for determining that healthcare claim elements comply with predetermined requirements including, health plan reimbursement conditions, health plan format requirements, a reimbursement formula, reimbursement constraints and a reimbursement computation procedure. A rule also may comprise a prescribed guide, a precept, or a model for how to present, conduct or regulate an action by using a form and data or the relations between form and data. In other embodiments, the rules repositories described herein may also be arranged as a single repository or multiple repositories in a different arrangement. Further, an exception as used herein encompasses the identification of an issue and mechanism to process that issue and claim elements as used herein may comprise a portion of a claim, a complete claim, individual records of a claim and record data associated with an individual patient encounter with a healthcare service provider. In addition a window as used herein comprises an image area used for display of desired text or graphics or other content to a user and is not limited to a Microsoft or any other particular operating environment.

#Centralized rules repository 74 enables consistency in consolidation and communication of rule sets across participants in the healthcare industry. Rules repository 74 contains up to date current rules for checking by unit 50 and execution by unit 46. The rules are expressed in a standard syntax and process standard claim data identifiers and value sets to ensure compatibility with multiple application platforms and health enterprises. The system of FIG. 1 supports collecting and combining rules across multiple healthcare entities for processing healthcare patient encounter information and associated claim data to ensure claim accuracy. An encounter as used herein comprises a patient encounter with a healthcare enterprise involving patient and healthcare enterprise interaction that has a financial or transaction consequence and may include for example a patient visit, phone call, inpatient stay or outpatient treatment etc. Centralized rules repository 74 ensures that system participants stay compliant with rapidly changing rules and regulations. Further, the use of clinical event-driven application of rules when needed (rather than sequential processing after the fact) gives confidence that requested actions occur without unexpected, late or retroactive claim denials occurring. Rules change frequently and especially in response to the introduction of new technology, procedures, and medications. Repository 74 advantageously maintains effective validity dates and decommissioning dates for rules as well as a record of obsolete or out-of date rules. Further, the selection and operation of rules in processing claim data is affected by particular dates associated with a patient healthcare encounter such as an admission date, birth date, discharge date, and treatment date.

#The FIG. 1 system invokes rules to automate the pre-registration, eligibility, registration authorization, claim generation, trial adjudication, claim submission, payment remittance, and post-remittance processes of a health care claim data processing cycle to provide seamless, accurate and prompt claim processing. The system facilitates coordination of employer and payer activities and ensures that pre-visit enrollee data is accurate. Thereby, if a patient uses a consumer portal (24) to schedule a visit or if a healthcare facility collects insurance information from a patient, medical necessity, referral and eligibility verification processing is automatically initiated. A claim is evaluated for accuracy and edited by a rule execution function 46 and adjudication unit 48, using the applicable rules in rules repository 74, both before the claim is completed (i.e. as individual claim elements for individual healthcare encounters post to the claim, for example) and again before the completed claim is submitted for payment. A variety of portals 20-28 in the FIG. 1 system are controlled and administered by interface 10 to provide claim data access to patients, payers, providers, employers and government agencies. The system facilitates healthcare provider compliance with governmental and payer rules through use of automated, rules-based editing and review systems.