System for providing consumer access to healthcare related information

#This invention concerns a system and user interface for use in supporting patient access to healthcare encounter related information and enabling a patient to initiate scheduling of an encounter and to update patient related healthcare encounter information.

#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 Healthcare claim adjudication and associated billing and payment process is encumbered with problems. Patients often do not understand the proffered reason for claim denial or rejection and are frustrated by the limited methods available for tracking and monitoring progress of a claim submitted to a healthcare payer organization. Known systems approach the problem from a healthcare payer or provider perspective. A provider tracks the status of each individual claim and follows-up with the payer. A payer would monitor the activities of the provider to check claim calculations are correct under current payer rules. Patients are provided limited methods of determining claim status or of determining status of other administrative and clinical healthcare procedures such as eligibility verification, pre-certification requests or referrals to specialists, for example. Compounding the problem associated with this task, is the fact that a single medical incident can generate multiple claims for each clinician involved (physician, surgeon, anesthesiologist, physical therapist, pathologist, radiologist) and a patient may be faced with the burden of contacting multiple different entities of a multi-faceted health system to determine the status of a matter. Further, the most common method of making such a contact currently in use is telephone access to a typically labyrinthine customer services department. A patient currently may have no viable way of knowing whether a claim has been submitted, rejected or paid. Also a submitted claim may have been denied for missing information that the patient could have readily provided if aware of the deficiency. Also, an access system should be secure and prevent unauthorized access to confidential medical data. A system according to invention principles addresses these requirements and associated problems.

#FIG. 1 shows an overall encounter data processing system enabling an authorized patient to access healthcare encounter related information, according to invention principles.

#FIG. 2 shows a system configuration enabling an authorized patient to access healthcare encounter related information, according to invention principles.

#FIG. 3 shows a flowchart of a process employed in providing an authorized patient with access to healthcare encounter related information by the system of FIGS. 1 and 2, according to invention principles.

#The inventors have advantageously recognized that it is desirable to provide a system capable of providing efficient patient access to information concerning pre-certifications, referrals, eligibility verification, healthcare services availability, co-payments, deductibles, claims and payment status. It is further desirable that such patient information access is available during convenient hours (ideally 24 hours a day every day) and from convenient locations. FIG. 1 shows an overall encounter data processing system enabling an authorized patient (or a consumer) to access healthcare encounter related information. 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, an interview, an examination, a procedure, a treatment related occurrence, an admission to a healthcare enterprise, a test or an order for medication etc. In the FIG. 1 system, aggregated healthcare encounter service, billing, and claim data in repository 68 is used to enable an authorized patient to access healthcare encounter related information concerning pre-certifications, referrals, eligibility verification, healthcare services availability, co-payments, deductibles, claims and payment status. The system securely provides a patient via the Internet, for example, with the information in a variety of formats including as a consolidated view of activity across multiple patient claims. A patient is thereby able to track data concerning an episode of care, plus has the opportunity to correct data that might result in erroneous billing. A patient is also able to access payer organization health plan insurance reimbursement and treatment eligibility rules including cumulative limits, family and personal deductible amounts, limits on the number of visits permitted in a predetermined period and reimbursement limits per particular medical condition (e.g., for a year or over a patient lifetime). A patient is similarly able to determine approved pharmacies or other service providers, obtain authorization for a second opinion, determine referral requirements and find approved medications as well as non-covered services. Further, the system of FIG. 1 enables an authorized user to access another individual's records (typically a family member or user that is fiscally responsible for that individual) and enables a patient to assign authority to another individual or entity to access his confidential information. Access is strictly controlled based on policy data supplied by the payer to prevent unauthorized access to confidential patient information. The FIG. 1 system also supports electronic dialog between a healthcare provider and a payer organization that allows a patient or fiscally responsible party to interact directly with payer organizations and healthcare providers to communicate concerns about information viewed or to request that incorrect information be corrected.

#The FIG. 1 aggregated healthcare encounter service, billing, and claim data repository 68 comprises a relational database linking a record of an encounter resulting in a claim with patient health plan reimbursement and eligibility rules as well as remittance records for a patient medical episode or illness. The database uses known techniques to logically link multiple encounters related to care including pre-admission testing, inpatient stay, outpatient follow-up, bills and payments across multiple providers and locations. Thereby repository 68 enables a user, such as a patient via consumer portal 24, to access information concerning a particular claim, encounter, patient coverage rule or remittance record. Similarly a user is able to view a history of claim updates and coverage rule changes that may impact claim submission and reimbursement. Repository 68 also enables a user to view elapsed time between events (discussed later) and to view activity of multiple individuals or of one or more individuals within a user defined time period.

#A rule as used herein comprises a procedure 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. 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. Further, a claim is an instrument used by insurance companies to recognize services and related changes but it does not create an absolute expectation of payment. In contrast, a bill (typically directed to a guarantor or other fiscally responsible party) is an expectation of payment.