Healthcare system and method for right-time claims adjudication and payment

A method for making payment on a charge from a provider for healthcare services that are provided to a patient at a provider location, wherein the services are subject to a healthcare plan administered by a first payer, and wherein a patient portion amount of the charge may not be covered by the healthcare plan, and wherein a second payer may be used for the patient portion, the method comprising:

• providing a healthcare provider system at the provider location, the provider system having a point of sale (POS) device for receiving a patient ID and a treatment code identifying healthcare services provided to the patient, and the provider system for identifying the first payer;
• electronically preparing a claim at the provider system for the first payer, the claim including the patient ID and the treatment code, after the patient healthcare services have been provided;
• transmitting the claim from the provider system to the first payer and to an estimating system;
• generating estimated EOB data at the estimating system as an estimated adjudication of the claim and in response to the claim, and transmitting the estimated EOB data to the provider system, the estimated EOB data representing at least the patient portion amount, wherein the estimating system generates the estimated EOB information based on location of the provider;
• displaying the estimated EOB data at a display device associated with the POS device at the provider system for the patient to authorize payment from the second payer for the patient portion amount based on the estimated EOB data;
• electronically submitting an authorization for payment from the provider system to a second payer system, in order to process real-time payment from the second payer while the patient is at the provider location;
• subsequently receiving at the provider system non-estimated EOB data from the first payer in response to the claim and that is separate from the estimated EOB data;
• and
• reconciling the non-estimated EOB data against the estimated EOB data.

A system for making payment for patient healthcare services to a provider of such services, where payment may be made by multiple payer sources, including a first payer to whom a health care claim is submitted and a second payer maintaining an account on behalf of the patient that may be used for amounts not paid by the first payer, the system comprising:

• a point of sale (POS) device for use by the provider in entering data, including at least a patient identification and a treatment code;
• a display device associated with the POS device;
• and
• a healthcare network linked to the POS terminal and to the second payer, the healthcare network for:
• receiving data entered at the POS terminal and in response to the received data electronically transmitting a healthcare claim to the first payer source and to an estimating system, after patient healthcare services have been provided to the patient;
• receiving from the estimating system an estimated explanation of benefits (EOB) message in response to the healthcare claim and as an estimated adjudication of the healthcare claim, the estimated EOB message provided to the POS device for display at the display device, the estimated EOB message including at least (a) information on a permitted charge corresponding to the treatment code and (b) information relating to a patient portion of such permitted charge that is not to be paid by the first payer;
• and
• posting an electronic transaction against the second payer account in response to receipt of the patient portion information, so that real-time payment of the patient portion to the provider may be made while the patient is at the provider location and after the estimated EOB message is received by the healthcare network and provided to the POS device;
• wherein the healthcare network subsequently receives a non-estimated EOB message from the first payer in response to the healthcare claim, and where a patient portion of the non-estimated EOB message is reconciled by the healthcare network against the patient portion of the estimated EOB message;
• and
• wherein the difference between the estimated EOB information and the non-estimated EOB information is used by the estimating system as a basis for calculating estimated EOB information for subsequent healthcare claims transmitted to the estimating system.