WO2005091201A2

WO2005091201A2 - Claim submission and processing system and method

Info

Publication number: WO2005091201A2
Application number: PCT/IB2005/000653
Authority: WO
Inventors: Gary Behenna; Jacques Malan Smit; Marina Van Der Merwe; Peter Kennedy; Susan Sandra Miller
Original assignee: Digital Healthcare Switch (Proprietary) Limited
Priority date: 2004-03-16
Filing date: 2005-03-15
Publication date: 2005-09-29
Also published as: WO2005091201A8

Abstract

A claim submission and processing system (10), the claim (12) being initiated by a healthcare provider (16) who has just attended to a patient (14), is disclosed. The system (10) comprises input means (18) for allowing the healthcare provider (16) to capture the relevant data of the claim (12) so as to compile a claim data set, intermediate processing means (22), and communication means (24) for allowing the claim data set to be sent electronically from the healthcare provider (16) to the intermediate processing means (22). Significantly, claim submission selection means is also provided for allowing the healthcare provider (16) to either send the claim data set to the intermediate processing means (22) immediately after a single patient encounter or send a plurality of claim data sets to the intermediate processing means at a later stage after a plurality of patient encounters.

Description

CLAIM SUBMISSION AND PROCESSING SYSTEM AND METHOD

BACKGROUND OF THE INVENTION

THIS invention relates to a claim submission and processing system and method, with the claim typically being a medical-related claim.

Presently, claims generated by healthcare practitioners for healthcare related services provided by the practitioner to patients are electronically submitted to the patients' medical schemes via an intermediate switching centre. The term "medical scheme", in broad terms, refers to any payor of a medical-related claim, and so includes conventional medical schemes/aids, as well as Pharmaceutical Benefit Managers (PBM's) as well as insurance companies. Currently, this claim submission process entails the submission of the claim in either batch or real time mode.

In the batch process, once a sufficiently large enough batch of claim submissions has been accumulated, the batch is transmitted to the switching centre as an electronic file. If required, the healthcare practitioner is able to print a report summarizing the batch of claim submissions that was sent to the switching centre. The switching centre then proceeds to validate the batch according to specific requirements, with individual claims either being accepted, in which case the claims are compiled into batches for, and then sent to, the various medical schemes, or rejected, in which case an electronic file is compiled for the rejected claims and sent back to the healthcare practitioner to enable them to take the required corrective action and to resubmit the claims. For real time claim submissions, each claim is sent by the healthcare practitioner to the switching centre, with the claims in turn then being entered directly electronically into the computer system of the relevant medical scheme. The medical scheme then processes the claim, with an immediate adjudicated or assessed response, either acceptance or rejection, then being sent back electronically to the originating healthcare practitioner via the switching centre or on paper.

However, the above two methods are in certain cases rather restrictive, in that they do not provide the healthcare practitioner with much flexibility regarding the submission and processing of the claim that take into account the modus operandi of the healthcare practitioner's practice. In addition, all medical schemes are not ready to accept real time claims at the same time, with a transition from batch to real time functionality still being required for a number of medical scheme systems. Finally, the methodology described above relies on human intervention at the practice to change the activation code of the scheme for real time claim submissions after they have been advised in writing to do so by the switching centre when a new scheme becomes real time-enabled. This process and take up is very slow and tedious.

It would therefore be desirable to provide a claim submission and processing system and method that addresses the above disadvantages.

SUMMARY OF THE INVENTION

According to a first aspect of the invention, there is provided a claim submission and processing system, the claim being initiated by a healthcare provider who has just attended to a patient, the system comprising: input means for allowing the healthcare provider to capture the relevant data of the claim so as to compile a claim data set; intermediate processing means; communication means for allowing the claim data set to be sent from the healthcare provider to the intermediate processing means; and claim submission selection means for allowing the healthcare provider to either send the claim data set to the intermediate processing means immediately after a single patient encounter or send a plurality of claim data sets to the intermediate processing means at a later stage after a plurality of patient encounters.

Conveniently, the system includes data translation means for translating the claim data set received from the healthcare provider into a data format that can be processed by a medical scheme associated with a particular patient.

In one version of the invention, the intermediate processing means transfers the claim data set to the patient's medical scheme via the communication means, for allowing the medical scheme to process the received claim and to provide an adjudicated response, either acceptance or rejection, which is sent back electronically to the healthcare provider's system via the intermediate processing means.

Alternatively, the intermediate processing means provides an instantly assessed claim, based on pre-determined criteria for each of the medical schemes, and electronically supplies the instantly assessed claim response back to the healthcare practitioner.

Typically, the healthcare provider can insert an indicator in the claim data set, prior to the claim data set being sent to the intermediate processing means, the indicator enabling the healthcare provider to specify in the claim data set that the patient has already paid for the services provided by the healthcare practitioner, and thus the patient needs to be reimbursed directly.

Preferably, at the time of compiling the claim data set, the healthcare provider can insert a request indicator requesting for verification that a specific patient is still a member of a particular medical scheme.

Advantageously, the system can be used to construct an electronic healthcare service request that can be electronically sent to a healthcare- related third party via the communication means, the electronic healthcare service request being used to request the third party to deliver a particular healthcare-related service to the patient.

Typically, the system can be used to construct and send a patient profile, comprising healthcare-related information relating to a particular patient, to a healthcare-related third party via the communication means.

Conveniently, the healthcare provider can attach and send electronic documents to the healthcare-related third party.

It is envisaged that healthcare-related third party is either another healthcare provider or a hospital.

Preferably, the communication means comprises a Virtual Private Healthcare Network (VPHN).

According to a second aspect of the invention, there is provided a claim submission and processing method, the claim being initiated by a healthcare provider who has just attended to a patient, the method including the steps of: allowing the healthcare provider to capture the relevant data of the claim so as to compile a claim data set; providing an intermediate processing means; allowing the claim data set to be sent from the healthcare provider to the intermediate processing means; and allowing the healthcare provider to either send the claim data set to the intermediate processing means immediately after a single patient encounter or send a plurality of claim data sets to the intermediate processing means at a later stage after a plurality of patient encounters.

Conveniently, the method includes the step of translating the claim data set received from the healthcare provider into a data format that can be processed by a medical scheme associated with a particular patient.

In one version of the invention, the method includes the step of transferring the claim data set to the patient's medical scheme, for allowing the medical scheme to process the received claim and to provide an adjudicated response, either acceptance or rejection, which is sent back electronically to the healthcare provider's system via the intermediate processing means.

Alternatively, the method includes the steps of allowing the intermediate processing means to provide an instantly assessed claim, based on predetermined criteria for each of the medical schemes, and supplying the instantly assessed claim response back to the healthcare practitioner.

Typically, the method further includes the step of allowing the healthcare provider to insert an indicator in the claim data set, prior to the claim data set being sent to the intermediate processing means, the indicator enabling the healthcare provider to specify in the claim data set that the patient has already paid for the services provided by the healthcare practitioner, and thus the patient needs to be reimbursed directly. Preferably, the method further includes the step of allowing the healthcare provider to insert a request indicator requesting for verification that a specific patient is still a member of a particular medical scheme.

Advantageously, the method further includes the step of allowing the healthcare provider to construct an electronic healthcare service request that can be electronically sent to a healthcare-related third party, the electronic healthcare service request being used to request the third party to deliver a particular healthcare-related service to the patient.

Typically, the method further includes the step of allowing the healthcare provider to construct and send a patient profile, comprising healthcare- related information relating to a particular patient, to a healthcare-related third party via the communication means.

Conveniently, the method further includes the step of allowing the healthcare provider to attach and send electronic documents to the healthcare-related third party.

BRIEF DESCRIPTION OF THE DRAWING

The only figure shows a schematic block diagram of a claim submission and processing system according to the present invention.

DESCRIPTION OF THE PREFERRED EMBODIMENT

With reference to the only figure, a claim submission and processing system 10 for facilitating the submission and subsequent processing of a medical-related claim 12 for a patient 14 that a healthcare provider 16 has just attended to, is shown. An input device 18, typically in the form of a computer, is used to facilitate the capturing of the relevant data of the claim 12 by either the healthcare provider 16 or an administrative person within the practice. The ultimate destination of the claim 12 is the patient's medical scheme 20, or, as indicated above, any other entity used by the medical scheme to stand in for the payment of the claim once successfully adjudicated.

The system 10 includes a switching centre hosting an intermediate processing means 22, with a communications network 24, defining a Virtual Private Healthcare Network (VPHN), facilitating all communications between the various parties. In particular, once a party is connected to the VPHN, any one participant has the ability to send electronically predefined transactions to any of the other participants via the switching centre. Medical schemes typically connect by means of leased line, Frame Relay Networks or via the Internet, and service providers by means of leased line, X25, dial-up connections, the Internet or wireless technology.

In particular, the network 24 allows the data of the claim 12 to be electronically transferred to the intermediate processing means 22, and then from the intermediate processing means 22 to the patient's medical scheme 20. Once the medical scheme 20 processes the claim to provide an adjudicated response, either acceptance or rejection, the medical scheme 20 sends the response back to the system of the service provider 16 via the intermediate processing means 22. Significantly, this to and fro claim submission process takes place in a single electronic connection, thereby greatly enhancing the turn-around time for claim submissions for the healthcare practitioner.

Significantly, at the time of capturing the claim data, the only decision that the healthcare provider 16 has to make is to specify whether the claim should be sent immediately (i.e. NOW), or whether it should be sent at some later time (i.e. LATER). For NOW, the claim would get sent after a single patient encounter, whereas for LATER a plurality of claims would all get sent to the intermediate processing means 22 at a later stage after a plurality of patient encounters. If the healthcare provider 16 indicates that the claim should be sent immediately, the claim data is then sent immediately to the intermediate processing means 22, which will then process the claim in any one of a number of ways. Some of these ways will be described in more detail further on in the specification. If, however, the claim data is to be sent later, then it is sent later, the point being that the healthcare provider 16 does not have to capture the claim data at that stage i.e. the claim data is captured at one point, but then simply sent to the intermediate processing means 22 at a later stage, together with all the other claims that have been assigned the LATER indicator.

Advantageously, the new methodology described above will streamline the process at the practice of the healthcare provider 16, regardless of the level of sophistication available from the different medical scheme systems. The implication for the healthcare provider 16 in choosing NOW or LATER is that the transmission and selection method allows for the most appropriate modus operandi for the practice. If, for example, the healthcare provider 16 sees a new patient and he wants to ensure that his risk is minimized, the best working practice would be to ensure that the claim is submitted while the patient is still at the practice of the service provider, to ensure that the response can be adhered and reacted to immediately. The adjudicated response from the medical scheme could indicate the amount that the patient must pay or it could also relate to conditions where prescribed drugs could cause the patient harm due to either current conditions or adverse reactions to other drugs that the patient may be taking.

The same reasoning applies if a patient changed from one medical scheme to another and the service provider needs to make sure that the correct rules are applied when the claim 12 is submitted. The current tendency of medical scheme members "buying down" to a more affordable option also increases the financial risk for the healthcare provider as the cheaper options make provision for a much smaller pool of benefits. In some instances, typically when the healthcare provider 16 will be seeing the patient for subsequent visits and all information has already been verified at the first visit of the patient, the healthcare provider 16 may submit the claim later or capture the claim immediately but select the option to be sent later. Also, where a practice administrator is capturing claims only after the patient has left the premises, the claim will most probably be submitted later, but the timing of the response will depend on the functioning of the medical scheme, as discussed below.

With this feature, the invention removes the need for the healthcare provider 16 or an administrative person within the practice, in his or her role as a data capturer, to make an informed decision at the time of capturing the claim. The intermediate processing means 22 will decide what the best possible action is that should be taken for a specific claim once it is received by the intermediate processing means 22. For example, claims of medical schemes that are real time enabled will be delivered in real-time by the intermediate processing means 22 even when the capturer (i.e. the healthcare provider 16 or an administrative person within the practice) has selected the LATER option for a particular claim. Similarly, where the healthcare provider has selected the claim to be sent immediately, but the medical scheme is not real time enabled, the intermediate processing means 22 will take appropriate action as described below under the heading "1. Instantly Assessed Claim (IAC)".

Advantageously, the system includes data translation means 26 for automatically translating the claim or service request into a format that can be processed by the particular medical scheme 20 that will be receiving claim 12.

As indicated above, there are a number of ways in which the intermediate processing means 22 can process the claim. These are described below: 1. Instantly Assessed Claim (IAC)

This feature of the present invention provides a more complete service to the healthcare provider 16, and is particularly applicable if the medical scheme is not real time enabled. In such a case, the intermediate processing means 22 automatically validates the claim against predefined validation rules within its own system, after which the response to this validated claim is electronically returned to the healthcare provider 16. In use, the intermediate processing means 22 will, through its own intelligence, take the appropriate action for a medical scheme that is not real time enabled and validate the claim according to the mentioned predefined rules. After the IAC has validated the claim, and the claim has passed all validation rules, the claim will be submitted to the medical scheme, typically with other claims in batch mode. If the claim fails, it will be sent back electronically to the healthcare practitioner with the relevant rejection code included thus enabling the healthcare practitioner to correct and resubmit the claim.

2. Member Paid Claim

This feature is implemented by the healthcare provider 16 inserting an indicator in the claim data that he or she sends to the intermediate processing means 22. This new indicator enables the healthcare provider 16 to specify in the claim data that the medical scheme 20 must reimburse the patient 14 directly, and not the healthcare provider 16.

The member paid indicator will indicate to the medical scheme processing system that the member/patient 14 has paid the healthcare provider 16 directly for his or her services, and must thus be directly reimbursed by the medical scheme 20. This is a significantly novel and unique feature, which will enable more practices to take part by submitting the claim electronically on behalf of the scheme member. It is also envisaged that scheme members will be able to submit member paid claims individually to the medical schemes through the VPHN. 3. Capitation claims

Various capitation models are used currently. The most traditional form of capitation is where both the medical scheme and the healthcare provider take equal risk in the supply and reimbursement of the rendered services. The healthcare provider is allocated a group of patients that have nominated that particular healthcare provider as being their preferred healthcare provider. The healthcare provider is then paid a fixed amount monthly for the full compliment of patients, regardless of the number of consultations or services they receive from that healthcare practitioner during that month.

At present, capitation claims are generally not submitted electronically to^* medical schemes. This has a tremendous impact on the long-term viability of capitation schemes as they (i.e. the medical schemes) require the claim information in order to correctly and accurately negotiate the fees for the subsequent years.

The data elements that are important in capitation claims are largely the same as for regular claims; however, capitation claims can also be submitted without any form of price attached. By including the capitation claim indicator in the claim submission, the medical schemes can continue to build the disease and claims profiles of capitation scheme members, while at the same time being able to ensure intelligent and correct handling of these claims in their systems.

4. Membership Status Validation (MSV)

The ability to electronically verify that a specific patient is still a member of the scheme, as indicated on the membership card, is of tremendous importance to the healthcare provider. This in itself is not a new function, but the ability to do the membership status validation from within the specific account of the patient in the practice management software of the healthcare provider is a big enhancement on the current modus operandi. In short, the implication of this facility means that the healthcare provider does not have to exit from the software to verify the status of the member. This will save time and will ensure that this functionality is more widely used due to this efficiency. Where applicable, MSV will be included as part of the validation done in IAC in the intermediate processing means 22 for selected schemes.

5. Electronic Remittance Advice (eRA)

The electronic remittance advice in itself is not a new concept; however, the instructions from the intermediate processing means 22 to the software vendor to incorporate this payment information back into the practice management application (PMA), is new. The standard paper generated remittance report is replaced with an electronic file that contains all the required data elements (payments, exclusions, rejections and part payments made by the scheme directly) to enable the detail of the electronic remittance to be automatically allocated where possible and reconciled to the individual claim line of the patient's account. The PMA must also ensure that the practice can print a listing of payments allocated as well as any rejections and exceptions that are indicated on specific transaction items or claims.

6. Electronic Patient Detail ( ePD)

The electronic patient detail (ePD) is a message that will be sent from a healthcare provider through the VPHN to an entity that is requested to deliver a service to that patient, such as entity 28 in the attached figure. The receiving entity 28 can be any service facility but is typically a hospital, pathology or radiology group, or another healthcare practitioner. This message will contain the static demographic information of the patient as well as any other relevant information pertaining to the service required from the receiving entity 28 i.e. for hospital claims, this will inter alia also include the co-morbidity codes as well as the primary diagnosis code. This message would also make provision to list all the allergies of the patient 14. The static information will include all the information required by the receiving entity 28 to automatically print (for patient signature) or upload the patient information directly into their computer system. This process will depend on the sophistication of the receiving entity's computer system. This would also contain the medical scheme information of the patient as well as that of the main member of the medical scheme. Full details of the party that is responsible for the account will also be included. The intermediate processing means 22 is also able to do a patient membership validation (i.e. MSV, as discussed above) while the message is on route to the receiving entity 28, and indicators would be added to the message to reflect the outcome of this validation. This negates the need for the receiving entity to redo this process, thus adding additional value to the ePD transaction.

As can be appreciated, there is a tremendous amount of information flowing through the intermediate processing means 22. As a result, there are a number of management reports that can be provided based on the claims flowing through the intermediate processing means 22, three of which will be discussed below:

1. Electronic Claims Profile (eCP)

This report provides a management view of claims data, which can be used to: - warn a healthcare practitioner about possible problem areas within his or her practice; encourage the healthcare practitioner to look at his or her practice as a business; - enable business critical information to be viewed at any time. Examples of eCP reports include the number of patient encounters submitted to the intermediate processing means for a selected period, by age and gender, diagnosis profile, top medicines dispensed for that period - by value or incidence, the average claim submission cycle in terms of numbers of days as well as common diagnoses. It also introduces more reports with drill-down capabilities i.e. the healthcare practitioner can select a report that will supply him /her with the age/gender profile of the patient for a selected medical scheme or for a selected diagnosis code. 2. Discipline Trend Review (DTR)

This management report will typically group the eCP reports of a defined group of individual healthcare practitioners into a combined view. This will comprise all the different eCP reports that the individual healthcare practitioner can view for his or her practice. Examples of DTR reports include age and gender for various medical schemes, dispensed medicines, reasons for rejections, as well as age and gender for a particular diagnosis.

3. Doctors WebDesk

This online facility allows a healthcare practitioner to access, amongst others, the following services: batch information regarding claims that have been submitted to the intermediate processing means; medical aid response on claims; membership validation; tracking of a specific patient's claim; and change of practice details on the intermediary switching service' computer system .

Claims

1. A claim submission and processing system, the claim being initiated by a healthcare provider who has just attended to a patient, the system comprising: input means for allowing the healthcare provider to capture the relevant data of the claim so as to compile a claim data set; intermediate processing means; communication means for allowing the claim data set to be sent electronically from the healthcare provider to the intermediate processing means; and claim submission selection means for allowing the healthcare provider to either send the claim data set to the intermediate processing means immediately after a single patient encounter or send a plurality of claim data sets to the intermediate processing means at a later stage after a plurality of patient encounters.

2. A claim submission and processing system according to claim 1 , wherein the system includes data translation means for translating the claim data set received from the healthcare provider into a data format that can be processed by a medical scheme associated with a particular patient.

3. A claim submission and processing system according to claim 2, wherein the intermediate processing means transfers the claim data set to the patient's medical scheme via the communication means, for allowing the medical scheme to process the received claim and to provide an adjudicated response, either acceptance or rejection, which is sent back electronically to the healthcare provider's system via the intermediate processing means.

4. A claim submission and processing system according to claim 2, wherein the intermediate processing means provides an instantly assessed claim, based on pre-determined criteria for each of the medical schemes, and electronically supplies the instantly assessed claim response back to the healthcare practitioner.

5. A claim submission and processing system according to any one of the preceding claims, wherein the healthcare provider can insert an indicator in the claim data set, prior to the claim data set being sent to the intermediate processing means, the indicator enabling the healthcare provider to specify in the claim data set that the patient has already paid for the services provided by the healthcare practitioner, and thus the patient needs to be reimbursed directly.

6. A claim submission and processing system according to any one of the preceding claims, wherein at the time of compiling the claim data set, the healthcare provider can insert a request indicator requesting for verification that a specific patient is still a member of a particular medical scheme.

7. A claim submission and processing system according to any one of the preceding claims, which can be used to construct an electronic healthcare service request that can be electronically sent to a healthcare-related third party via the communication means, the electronic healthcare service request being used to request the third party to deliver a particular healthcare-related service to the patient.

8. A claim submission and processing system according to any one of the preceding claims, which can be used to construct and send a patient profile, comprising healthcare-related information relating to a particular patient, to a healthcare-related third party via the communication means.

9. A claim submission and processing system according to either claim 7 or claim 8, wherein the healthcare provider can attach and send electronic documents to the healthcare-related third party.

10. A claim submission and processing system according to any one of claims 7 to 9, wherein the healthcare-related third party is either another healthcare provider or a hospital.

11. A claim submission and processing system according to any one of the preceding claims, wherein the communication means comprises a Virtual Private Healthcare Network (VPHN).

12. A claim submission and processing method, the claim being initiated by a healthcare provider who has just attended to a patient, the method including the steps of: allowing the healthcare provider to capture the relevant data of the claim so as to compile a claim data set; providing an intermediate processing means; allowing the claim data set to be sent from the healthcare provider to the intermediate processing means; and allowing the healthcare provider to either send the claim data set to the intermediate processing means immediately after a single patient encounter or send a plurality of claim data sets to the intermediate processing means at a later stage after a plurality of patient encounters.

13. A claim submission and processing method according to claim 12, which includes the step of translating the claim data set received from the healthcare provider into a data format that can be processed by a medical scheme associated with a particular patient.

14. A claim submission and processing method according to claim 13, wherein the method includes the step of transferring the claim data set to the patient's medical scheme, for allowing the medical scheme to process the received claim and to provide an adjudicated response, either acceptance or rejection, which is sent back electronically to the healthcare provider's system via the intermediate processing means.

15. A claim submission and processing method according to claim 13, which includes the steps of allowing the intermediate processing means to provide an instantly assessed claim, based on predetermined criteria for each of the medical schemes, and supplying the instantly assessed claim response back to the healthcare practitioner.

16. A claim submission and processing method according to any one of claims 12 to 15, which further includes the step of allowing the healthcare provider to insert an indicator in the claim data set, prior to the claim data set being sent to the intermediate processing means, the indicator enabling the healthcare provider to specify in the claim data set that the patient has already paid for the services provided by the healthcare practitioner, and thus the patient needs to be reimbursed directly.

17. A claim submission and processing method according to any one of claims 12 to 16, which further includes the step of allowing the healthcare provider to insert a request indicator requesting for verification that a specific patient is still a member of a particular medical scheme.

18. A claim submission and processing method according to any one of claims 12 to 17, which further includes the step of allowing the healthcare provider to construct an electronic healthcare service request that can be electronically sent to a healthcare-related third party, the electronic healthcare service request being used to request the third party to deliver a particular healthcare-related service to the patient.

19. A claim submission and processing method according to any one of claims 12 to 18, which further includes the step of allowing the healthcare provider to construct and send a patient profile, comprising healthcare-related information relating to a particular patient, to a healthcare-related third party via the communication means.

20. A claim submission and processing method according to either claim 18 or claim 19, which further includes the step of allowing the healthcare provider to attach and send electronic documents to the healthcare-related third party.