Device for reducing fraud, waste, and abuse in the ordering and performance of medical testing and methods for using the same
AssigneeOptum, Inc.
InventorsJohn L. WILSON, François CHARETTE
Life of this patent
Estimating the term…
Abstract
Provided is a lab clearinghouse device configured to reduce fraud, waste, and abuse in the ordering and performance of medical testing. The lab clearinghouse device is configured to communicate with a plurality of medical laboratories, medical providers, and lab payers to efficiently and effectively reduce fraud, waste, and abuse in the ordering and performance of medical testing.
Claims20
A device for reducing fraud, waste, and abuse in the ordering and performance of medical tests across a plurality of medical laboratories, medical providers, and lab payers, the device comprising a processor and a memory storing computer instructions that, when executed by the processor, cause the device to:
- receive a lab request from a lab request initiator, the lab request initiator being associated with at least one medical provider of the plurality of medical providers, wherein the lab request comprises an order for one or more medical tests to be performed;
- determine whether at least one of fraud, waste, or abuse in the lab request is likely by determining whether the lab request aligns with pre-established data associated with the lab request,
- wherein the pre-established data associated with the lab request includes patient data, physician data, provider data, lab data, payer data, or a combination thereof;
- approve or deny the lab request based on the determination of whether at least one of fraud, waste, or abuse in the lab request is likely,
- wherein approving the lab request comprises:
- generating lab instructions associated with the lab request after determining whether at least one of fraud, waste, or abuse in the lab request is likely, and
- transmitting the lab instructions associated with the lab request to one laboratory of the plurality of medical laboratories for performance of one or more corresponding medical tests, and
- wherein denying the lab request comprises transmitting a lab request denial to the lab request initiator, the lab request denial indicating that the lab request needs to be revised.
A method of reducing fraud, waste, and abuse in the ordering and performance of medical testing across a plurality of patients, medical laboratories, medical providers, and lab payers, the method comprising:
- receiving, by a fraud, waste, and abuse circuitry, a lab request from a lab request initiator, the lab request initiator being associated with at least one medical provider of the plurality of medical providers, wherein the lab request comprises an order for one or more medical tests to be performed;
- determining, by an analytical engine, whether at least one of fraud, waste, or abuse in the lab request is likely by determining whether the lab request aligns with pre-established data associated with the lab request,
- wherein the pre-established data associated with the lab request includes patient data, physician data, provider data, lab data, payer data, or a combination thereof;
- approving or denying the lab request based on the determination of whether at least one of fraud, waste, or abuse in the lab request is likely,
- wherein approving the lab request comprises:
- generating, by the analytical engine, lab instructions associated with the lab request after determining whether at least one of fraud, waste, or abuse in the lab request is likely, and
- transmitting, by a communications interface, the lab instructions associated with the lab request to one laboratory of the plurality of medical laboratories for performance of one or more corresponding medical tests, and
- wherein denying the lab request comprises transmitting, by the communications interface, a lab request denial to the lab request initiator, the lab request denial indicating that the lab request needs to be revised.
A computer program product is provided comprising a non-transitory computer readable medium having computer program instructions stored therein, said computer program instructions, when executed by a processor, reduce fraud, waste, and abuse in the ordering and performance of medical testing across a plurality of patients, medical laboratories, medical providers, and lab payers, by causing the computer program product to:
- receive a lab request from a lab request initiator, the lab request initiator being associated with at least one medical provider of the plurality of medical providers, wherein the lab request comprises an order for one or more medical tests to be performed;
- determine whether fraud, waste, or abuse are likely by determining whether the lab request aligns with pre-established data associated with the lab request,
- wherein the pre-established data associated with the lab request includes patient data, physician data, provider data, lab data, payer data, or a combination thereof;
- approve or deny the lab request based on the determination of whether fraud, waste, or abuse are likely,
- wherein approving the lab request comprises:
- generating lab instructions associated with the lab request after determining whether at least one of fraud, waste, or abuse in the lab request is likely, and
- transmitting the lab instructions associated with the lab request to one laboratory of the plurality of medical laboratories for performance of the lab instructions, and
- wherein denying the lab request comprises transmitting a lab request denial to the lab request initiator to revise the lab request, the lab request denial indicating that the lab request needs to be revised.
Dependencies are inferred from the claim text.