System and method for processing health care insurance claims
OwnerRobert Gary Stein, Paul John Brusil +1inventors
InventorsRobert Gary Stein, Paul John Brusil, Nancy Roguski Brusil
Life of this patent
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Abstract
A system for processing health care insurance claims is constructed in which the bulk of the claims processing burden is distributed to a server located at the office of the care provider. Patient data relative to patients under a provider's care is downloaded to the provider server with adjudication software required by the patient's insurance coverage. Claims adjudication occurs in real time at the provider.
Claims46
A system for processing health care insurance claims among a health care provider, a patient and said patient's insurance carrier comprising:
- a provider server operatively established at the service provider, said provider server further comprising:
- a provider storage medium for storing patient data and adjudication software received from a remote source;
- a provider payment determination processor operatively associated with said storage medium to process patient data, using said payment adjudication software to obtain an adjudicated payment request;
- a provider communication interface for receiving data and sending data including said payment request over an external communication link in a secure manner;
- and
- a carrier server operatively established at the insurance carrier, said carrier server further comprising:
- a carrier storage medium for storing an authoritative version of patient data and insurance payment adjudication software;
- a carrier payment administration processor for receiving said payment request and causing a payment to be made to said provider in accordance with said claim submittal;
- and
- a carrier communication interface for receiving data including said payment request and sending data over said external communication link in a secure manner;
- and
- wherein said communication link connects said provider and carrier servers through said provider and carrier communication interfaces.
A computer based method of processing health care insurance claims between a provider server and a carrier server comprising the steps of:
- providing patient data and claims adjudication software for storage on said provider server;
- adjudicating, at said provider server, a claim relating to a particular service using said patient data and adjudication software stored on said provider server;
- generating a payment request at said provider server based on said adjudicated claim;
- establishing a secure communication link between said provider and carrier servers;
- sending said payment request from said provider server to said carrier server;
- and
- processing said payment request at said carrier server and sending payment from said carrier server to said provider server.
A system for processing health insurance claims that require expert review comprising:
- a series of processors distributed between a provider and an insurance carrier wherein said processors cooperate through a communications link to:
- generate and securely store a treatment plan file containing a plan of treatment and supporting data related to said insurance claim;
- provide guidelines for conducting said expert review;
- process applications by experts for reviewing said treatment plan and assign an expert to review said treatment plan;
- and
- wherein said series of processors are selectably accessible to allow an expert to apply to review a treatment plan, have limited and secure access to said treatment plan, and generate a report assessing said treatment plan.
Dependencies are inferred from the claim text.