US 6,826,536 B1Granted

Health care billing monitor system for detecting health care provider fraud

OwnerBert Formaninventor

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Abstract

A health care information management system uses a pre-existing database of medical specialty claims, such as anesthesia claims, to profile the billing behavior of medical specialist providers, such as anesthesiologists. The software helps the user to determine which of the claims submitted by the providers are within accepted guidelines and industry standards. The software identifies providers who have submitted improper false claims. This is accomplished by comparing submitted claims with a database of histories of prior claims, as well as records of time accumulated data supplied by sources originating from hospitals, physicians and societies. The software incorporates unique triggers, which highlight those claims that indicate possible fraudulent submission. The system develops a profile of a provider's billing behavior and compares it to his peers. The software uses trigger filters to alert the insurance carrier if the provider's billing falls outside of a predetermined norm.

Claims12

Dependent claims

A data processing system for detecting health care provider fraud, comprising:

a. computer processor means for processing data;
b. computer storage means for storing data on a storage medium;
c. first means for initializing the storage medium;
d. second means for processing data regarding payment claims submitted by health care providers to payers wherein said payment claim data is processed to identify and flag fraud-suspect inconsistencies and anomalies regarding payments claims submitted for payment by health care providers;
e. third means for calibrating the processed data to enable appropriate identification of the fraud suspect inconsistencies and anomalies;
f. fourth means for fraud-profiling of individual health providers based on an accumulated history of claims submitted by an individual health care provider;
said data comprising an accumulated individual provider claim history of the individual health care provider;
said fourth means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium
i. data comprising an accumulated history of discrete data representing claims submitted for payment by an individual health care provider being profiled;
and
ii. subjecting said data comprising said accumulated individual provider claim history to at least one profiling modifier fraud-flag data processing filter, said profiling filter identifying and fraud-flagging inconsistencies between said accumulated claim submission history of said individual provider when those data are compared to the normative health care parameters for the same medical care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases.

8 more elements

A data processing system for detecting health care provider fraud, comprising:

a. computer processor means for processing data;
b. computer storage means for storing data on a storage medium;
c. first means for initializing the storage medium,
d. second means for processing data regarding payment claims submitted by health care providers to payers wherein said payment claim data is processed to identify and flag fraud-suspect inconsistencies and anomalies regarding payments claims submitted for payment by health care providers;
e. third means for calibrating the processed data to enable appropriate identification of the fraud-suspect inconsistencies and anomalies;
fourth means for fraud-profiling of individual health providers based on an accumulated history of claims submitted by an individual health care provider;
further wherein:
a. said first means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium individual health care provider payment claim data;
and
b. said second means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium data comprising at least one fraud-flag data processing filter to identify and flag fraud-suspect inconsistencies and anomalies regarding payment claims submitted for payment by health care providers;
and
c. said third means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium calibrating data for said at least one fraud-flag data processing filter, said calibrating data comprising
i. reference data regarding health care procedure billing parameters, said billing parameters data being furnished from health care industry, insurance industry, and/or governmental health care insurance payer information data bases;
and
d. said fourth means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium
i. data comprising an accumulated history of discrete data representing claims submitted for payment by an individual health care provider being profiled;
and
ii. subjecting said data comprising said accumulated individual provider claim history to at least one profiling modifier fraud-flag data processing filter, said profiling filter identifying and fraud-flagging inconsistencies between said accumulated claim submission history of said individual provider when those data are compared to the normative health care parameters for the same medical care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases.

15 more elements

Dependencies are inferred from the claim text.

Facts

Application: 09/620,320Filed 22 Jul 2000
Granted: 30 Nov 2004
Term ends: Not estimatedThe source records don’t support an estimate.

Classification6 codes

G06Q 40/02
Finance; Insurance; Tax strategies; Processing of corporate or income taxes: banking, e.g. interest calculation or account maintenance
G06Q 10/10
Administration; Management: office automation; Time management
G06Q 40/08
Finance; Insurance; Tax strategies; Processing of corporate or income taxes: insurance
G16H 30/20
ICT specially adapted for the handling or processing of medical images: for handling medical images, e.g. DICOM, HL7 or PACS