WO2019152056A1 - Dispositif pour la gestion centralisée d'essais médicaux et procédés d'utilisation de celui-ci - Google Patents

Dispositif pour la gestion centralisée d'essais médicaux et procédés d'utilisation de celui-ci Download PDF

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Publication number
WO2019152056A1
WO2019152056A1 PCT/US2018/016901 US2018016901W WO2019152056A1 WO 2019152056 A1 WO2019152056 A1 WO 2019152056A1 US 2018016901 W US2018016901 W US 2018016901W WO 2019152056 A1 WO2019152056 A1 WO 2019152056A1
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WIPO (PCT)
Prior art keywords
lab
request
data
medical
lab request
Prior art date
Application number
PCT/US2018/016901
Other languages
English (en)
Inventor
John L. Wilson
Francois Charette
Original Assignee
Optum, Inc.
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Optum, Inc. filed Critical Optum, Inc.
Priority claimed from US15/888,682 external-priority patent/US11282591B2/en
Priority claimed from US15/888,721 external-priority patent/US10930391B2/en
Priority claimed from US15/888,763 external-priority patent/US10978183B2/en
Publication of WO2019152056A1 publication Critical patent/WO2019152056A1/fr

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Classifications

    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q50/00—Systems or methods specially adapted for specific business sectors, e.g. utilities or tourism
    • G06Q50/10—Services
    • G06Q50/22—Social work
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q10/00—Administration; Management
    • G06Q10/08—Logistics, e.g. warehousing, loading or distribution; Inventory or stock management
    • G06Q10/087—Inventory or stock management, e.g. order filling, procurement or balancing against orders
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q30/00—Commerce
    • G06Q30/018—Certifying business or products
    • G06Q30/0185—Product, service or business identity fraud
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q30/00—Commerce
    • G06Q30/04—Billing or invoicing

Definitions

  • Laboratory medicine involves the process of capturing specimens and performing tests on the specimens.
  • Applicant has identified a number of deficiencies and problems associated with conventional processing of medical laboratory orders and results. Through applied effort, ingenuity, and innovation, many of these identified problems have been solved by developing solutions that are included in embodiments of the present invention, many examples of which are described in detail herein.
  • embodiments of the present invention include methods, devices, and computer program products for facilitating laboratory medicine processing.
  • a device for centralized management of medical tests across a plurality of medical providers, a plurality of lab payers, and a plurality of laboratories, the device including 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 includes an order for one or more medical tests to be performed; derive, using the lab request, a lab code associated with a lab fee, wherein the lab code is specific to the one or more medical tests; cause the lab request to be adjudicated; and approve or deny the lab request based on adjudicating the lab request.
  • Approving the lab request includes transmitting the lab fee indication to one lab payer of the plurality of lab payers, generating lab instructions associated with the lab request after the lab request has been adjudicated, 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.
  • Denying the lab request includes transmitting a lab request denial to the lab request initiator, the lab request denial indicating that the lab request needs to be revised.
  • the device may further include computer instructions that, when executed by the processor, cause the device to cause the lab request to be adjudicated by causing the device to analyze patient data, physician data, provider data, laboratory data, payer data, or a combination thereof; and determine a likelihood of payment by at least one lab payer of the plurality of lab payers by comparing the patient data, physician data, provider data, lab data, payer data, or combinations thereof to the lab request.
  • the likelihood of payment by the at least one lab payer of the plurality of lab payers may be based on a pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof.
  • the pattern of activity may be established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof and may be based on a series of prior medical tests associated with a patient, physician, provider, laboratory, payer, or combinations thereof.
  • the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on a series of prior payments made by a patient, payer, or combinations thereof.
  • the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on established procedures associated with a patient, payer, or combinations thereof.
  • the device may further include computer instructions, when executed by the processor, further cause the device to retrieve patient data, physician data, provider data, lab data, payer data, or a combination thereof from one or more external devices operated by one or more of the plurality of medical laboratories, medical providers, lab payers, or combinations thereof. Causing the adjudication of the lab request may be based on at least a portion of the patient data, physician data, provider data, lab data, payer data, or a combination thereof retrieved from the one or more external devices.
  • the lab request denial may include a suggested revised lab request.
  • the computer instructions when executed by the processor, may cause the device to cause adjudication of the lab request by causing the device to translate the lab request to a lab request indication and transmit the lab request indication to a lab payer.
  • the lab request indication may include a transmission containing information sufficient to enable the lab payer to determine a likelihood of approval of the lab request associated with the lab request indication.
  • the computer instructions when executed by the processor, may further cause the device to receive a lab payment indication from the at least one lab payer of the plurality of lab payers prior to generating lab instructions associated with the lab request.
  • the computer instructions when executed by the processor, may further cause the device to receive lab results from the at least one laboratory of the plurality of medical laboratories and transmit at least part of a lab payment to the at least one laboratory of the plurality of medical laboratories.
  • the computer instructions may, when executed by the processor, further cause the device to transmit the lab results to the lab request initiator.
  • a method for providing centralized management of medical tests across a plurality of medical providers, a plurality of lab payers, and a plurality of laboratories.
  • the method may include receiving, by a lab clearinghouse circuitry, a lab request from a lab request initiator.
  • the lab request initiator may be associated with at least one medical provider of the plurality of medical providers and the lab request may include an order for one or more medical tests to be performed.
  • the method may also include translating, by an analytical engine, the lab request to a lab code associated with a lab fee.
  • the lab code may be specific to the one or more medical tests.
  • the method may also include causing, by the analytical engine, the lab request to be adjudicated and approving or denying the lab request based on adjudicating the lab request.
  • Approving the lab request may include transmitting, by a communications interface, the lab fee to one lab payer of the plurality of lab payers; generating, by the analytical engine, lab instructions associated with the lab request after the lab request has been adjudicated; and transmitting, by the communications interface, the lab instructions associated with the lab request to one laboratory of the plurality of medical laboratories for performance of the lab instructions.
  • Denying the lab request may include 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.
  • causing the lab request to be adjudicated may include analyzing, by the analytical engine, patient data, physician data, provider data, laboratory data, payer data, or combinations thereof; and determining, by the analytical engine, a likelihood of payment by at least one lab payer of the plurality of lab payers by comparing the patient data, physician data, provider data, lab data, payer data, or combinations thereof to the lab request.
  • the likelihood of payment by the at least one lab payer of the plurality of lab payers may be based on a pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof.
  • the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on a series of prior medical tests associated with a patient, physician, provider, laboratory, payer, or combinations thereof. In some embodiments, the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on a series of prior payments made by a patient, payer, or combinations thereof. In some embodiments, the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on established procedures associated with a patient, payer, or combinations thereof.
  • the method may further include retrieving, by the lab clearinghouse circuitry, patient data, physician data, provider data, lab data, payer data, or combinations thereof from one or more external devices operated by one or more of the plurality of medical laboratories, medical providers, lab payers, or combinations thereof.
  • the data retrieved may be used in adjudicating the lab request.
  • a computer program product may include a non-transitory computer readable medium having computer program instructions stored therein.
  • the computer program instructions when executed by a processor may provide centralized management of medical tests across a plurality of medical providers, a plurality of lab payers, and a plurality of laboratories, by causing the computer program product to receive a lab request from a lab request initiator.
  • the lab request initiator may be associated with at least one medical provider of the plurality of medical providers and the lab request may include an order for one or more medical tests to be performed.
  • the computer program instructions may also cause the computer program product to translate the lab request to a lab code associated with a lab fee.
  • the lab code may be specific to the one or more medical tests.
  • the computer program instructions may also cause the computer program product to cause the lab request to be adjudicated and approve or deny the lab request based on adjudicating the lab request.
  • Approving the lab request may include transmitting the lab fee to one lab payer of the plurality of lab payers, generating lab instructions associated with the lab request after the lab request has been adjudicated, 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.
  • Denying the lab request may include transmitting a lab request denial to the lab request initiator. The lab request denial may indicate that the lab request needs to be revised.
  • 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 including 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 may be associated with at least one medical provider of the plurality of medical providers and the lab request may include an order for one or more medical tests to be performed.
  • the computer instructions when executed by the processor, may cause the device to 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.
  • the pre-established data associated with the lab request may include patient data, physician data, provider data, lab data, payer data, or a combination thereof.
  • the computer instructions when executed by the processor, may cause the device to 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.
  • Approving the lab request may include 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.
  • Denying the lab request may include transmitting a lab request denial to the lab request initiator, the lab request denial indicating that the lab request needs to be revised.
  • the pre-established data associated with the lab request may include medical history of a patient associated with the lab request, wherein the medical history of the patient includes medical tests requested by a plurality of different providers.
  • the pre-established data associated with the lab request may form a pre-established practice regarding ordering of lab requests by the plurality of medical providers.
  • the pre-established data associated with the lab request may include persistent patient data associated with the lab request.
  • the computer instructions when executed by the processor, may cause the device to transmit a warning indication to a patient device associated with at least one of the plurality of patients.
  • the warning indication may be configured to indicate that fraud, waste, abuse, or a combination thereof is suspected based on the determination of whether at least one of fraud, waste, or abuse in the lab request is likely.
  • the computer instructions when executed by the processor, may cause the warning indication to be transmitted prior to generating lab instructions associated with the lab request 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.
  • the computer instructions when executed by the processor, may cause the device to transmit a request for additional patient data, physician data, provider data, lab data, payer data, or a combination thereof to one or more external devices operated by one or more of the plurality of medical laboratories, medical providers, lab payers, or a combination thereof.
  • the computer instructions when executed by the processor, may further cause the device to transmit a lab fee indication to one lab payer of the plurality of lab payers prior to generating lab instructions associated with the lab request 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.
  • the lab request denial may include a suggested revised lab request.
  • the suggested revised lab request may include at least one of a suggested revised medical laboratory, suggested revised medical test, or a combination thereof.
  • the computer instructions when executed by the processor, may further cause the device to receive a lab payment from at least one lab payer of the plurality of lab payers prior to generating lab instructions associated with the lab request.
  • the computer instructions when executed by the processor, may further cause the device to receive lab results from the at least one laboratory of the plurality of medical laboratories and transmit at least part of the lab payment to the at least one laboratory of the plurality of medical laboratories.
  • the computer instructions when executed by the processor, may further cause the device to transmit the lab results to the lab request initiator.
  • a method for 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 may include receiving, by a fraud, waste, and abuse circuitry, a lab request from a lab request initiator.
  • the lab request initiator may be associated with at least one medical provider of the plurality of medical providers and the lab request may include an order for one or more medical tests to be performed.
  • the method may also include 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.
  • the pre- established data associated with the lab request may include patient data, physician data, provider data, lab data, payer data, or a combination thereof.
  • the method may also include 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.
  • Approving the lab request may include 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.
  • Denying the lab request may include 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.
  • the pre-established data associated with the lab request may include medical history of a patient associated with the lab request, wherein the medical history of the patient includes medical tests requested by a plurality of different providers.
  • the pre-established data associated with the lab request may form a pre-established practice regarding ordering of lab requests by the plurality of medical providers.
  • when determining whether fraud, waste, or abuse are likely may include generating, by the analytical engine, and transmitting, by the communications interface, a warning indication to a patient device associated with at least one of the plurality of patients.
  • the warning indication may be configured to indicate that fraud, waste, abuse, or a combination thereof is suspected.
  • generating and transmitting the warning indication may occur prior to generating lab instructions associated with the lab request 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.
  • the lab request denial may include a suggested revised lab request.
  • the suggested revised lab request may include at least one of a suggested revised medical laboratory, suggested revised medical test, or a combination thereof.
  • determining whether fraud, waste, or abuse are likely may include transmitting, by the communications interface, a request for additional patient data, physician data, provider data, lab data, payer data, or a combination thereof to one or more external devices operated by one or more of the plurality of medical laboratories, medical providers, lab payers, or a combination thereof.
  • a computer program product including 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.
  • the lab request may include an order for one or more medical tests to be performed.
  • the computer program instructions when executed by the processor, cause the computer to determine whether fraud, waste, or abuse are likely by determining whether the lab request aligns with pre-established data associated with the lab request.
  • the pre-established data associated with the lab request may include patient data, physician data, provider data, lab data, payer data, or a combination thereof.
  • the computer program instructions when executed by the processor, also cause the computer to approve or deny the lab request based on the determination of whether fraud, waste, or abuse are likely.
  • Approving the lab request may include 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.
  • Denying the lab request may include 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.
  • a device for approving medical tests across a plurality of medical providers, a plurality of lab payers, and a plurality of laboratories, the device including 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 may be associated with at least one medical provider of the plurality of medical providers and the lab request may include an order for one or more medical tests to be performed.
  • the computer instructions when executed by the processor, cause the device to evaluate the lab request. Evaluating the lab request may include determining the appropriateness of the lab request by comparing patient data, physician data, provider data, lab data, payer data, or a combination thereof to the lab request.
  • the computer instructions when executed by the processor, cause the device to approve or deny the lab request based on the appropriateness of the lab request.
  • Approving the lab request may include generating lab instructions associated with the lab request for performance of the lab instructions after determining that the lab request is appropriate, 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.
  • Denying the lab request may include transmitting a lab request denial if the lab request is determined not to be appropriate.
  • the lab instructions may specify the laboratory of the plurality of laboratories for performance of the lab instructions and the one or more medical tests to be performed by the laboratory.
  • the appropriateness of the lab request may be determined based on a degree of quality of the laboratory.
  • the appropriateness of the lab request may be determined based on a medical suitability of the medical tests to a patient’s diagnosis, the patient being associated with the lab request.
  • the appropriateness of the lab request may be determined based on a completeness of the lab request, an error in the lab request, cost associated with the lab request, timeliness of a laboratory for performance of the one or more medical tests, location of the laboratory for performance of the one or more medical tests, or a combination thereof.
  • the appropriateness of the lab request may be determined based on an insurance policy of a patient associated with the lab request.
  • the computer instructions may, when executed by the processor, further cause the device to retrieve patient data, physician data, provider data, lab data, payer data, or a combination thereof from one or more external devices operated by one or more of the plurality of medical laboratories, medical providers, lab payers, or a combination thereof when evaluating the lab request. Evaluating the lab request may be based on at least a portion of the patient data, physician data, provider data, lab data, payer data, or a combination thereof retrieved from the one or more external devices.
  • the lab request denial may include a suggested revised lab request.
  • the computer instructions may, when executed by the processor, further cause the device to receive a lab payment from the at least one lab payer of the plurality of lab payers prior to generating lab instructions associated with the lab request.
  • the computer instructions may, when executed by the processor, further cause the device to receive lab results from the at least one laboratory of the plurality of medical laboratories and transmit at least part of the lab payment to the at least one laboratory of the plurality of medical laboratories.
  • the computer instructions may, when executed by the processor, further cause the device to transmit the lab results to the lab request initiator.
  • a method for approving medical tests across a plurality of medical laboratories, medical providers, and lab payers, the method including receiving, by a lab management 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; evaluating, by an analytical engine, the lab request, wherein evaluating the lab request comprises determining the appropriateness of the lab request by comparing patient data, physician data, provider data, lab data, payer data, or a combination thereof to the lab request; and approving or denying the lab request based on the appropriateness of the lab request.
  • generating lab instructions may include developing instructions specifying the laboratory of the plurality of laboratories for performance of the lab instructions and specifying the one or more medical tests to be performed by the laboratory.
  • the appropriateness of the lab request may be determined based on a degree of quality of the laboratory.
  • the appropriateness of the lab request may be determined based on a medical suitability of the medical tests to a patient’s diagnosis, the patient being associated with the lab request.
  • the appropriateness of the lab request may be determined based on a completeness of the lab request, an error in the lab request, cost associated with the lab request, timeliness of a laboratory for performance of the one or more medical tests, location of the laboratory for performance of the one or more medical tests, or a combination thereof.
  • the appropriateness of the lab request may be determined based on an insurance policy of a patient associated with the lab request.
  • the method further includes retrieving patient data, physician data, provider data, lab data, payer data, or a combination thereof from one or more external devices operated by one or more of the plurality of medical laboratories, medical providers, lab payers, or a combination thereof. Evaluating the lab request may be based on at least a portion of the patient data, physician data, provider data, lab data, payer data, or a combination thereof retrieved from the one or more external devices.
  • the lab request denial may include a suggested revised lab request.
  • a computer program product including a non-transitory computer readable medium having computer program instructions stored therein, said computer program instructions when executed by a processor approve medical tests across a plurality of medical providers, a plurality of lab payers, and a plurality of laboratories, 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; evaluate the lab request, wherein evaluating the lab request comprises determining the appropriateness of the lab request by comparing patient data, physician data, provider data, lab data, payer data, or a combination thereof to the lab request; and approve or deny the lab request based on the appropriateness of the lab request.
  • FIG. 1 illustrates an example system in accordance with some embodiments discussed herein;
  • FIG. 2 illustrates a schematic block diagram of circuitry that can be included in a computing device in accordance with some embodiments discussed herein;
  • FIG. 3 illustrates an example lab clearinghouse data store in accordance with some embodiments discussed herein;
  • FIG. 4a illustrates example lab clearinghouse circuitry in accordance with some embodiments discussed herein;
  • FIG. 4b illustrates example fraud, waste, and abuse circuitry in accordance with some embodiments discussed herein;
  • FIG. 4c illustrates example lab management circuitry in accordance with some embodiments discussed herein;
  • FIG. 5a illustrates a flow diagram of exemplary operations of a lab clearinghouse system including lab clearinghouse circuitry in accordance with some embodiments discussed herein
  • FIG. 5b illustrates a flow diagram of exemplary operations of a lab clearinghouse system including fraud, waste, and abuse circuitry in accordance with some embodiments discussed herein;
  • FIG. 5c illustrates a flow diagram of exemplary operations of a lab clearinghouse system including lab management circuitry in accordance with some embodiments discussed herein;
  • FIG. 6 illustrates a flow diagram of exemplary operations of a medical provider in accordance with some embodiments discussed herein;
  • FIG. 7 illustrates a flow diagram of exemplary operations of a lab payer in accordance with some embodiments discussed herein.
  • FIG. 8 illustrates a flow diagram of exemplary operations of a laboratory in accordance with some embodiments discussed herein.
  • the terms“data,”“content,”“digital content,”“digital content object,”“information,” and similar terms may be used interchangeably to refer to data capable of being transmitted, received, and/or stored in accordance with embodiments of the present invention. Thus, use of any such terms should not be taken to limit the spirit and scope of embodiments of the present invention.
  • a computing device is described herein to receive data from another computing device
  • the data may be received directly from the another computing device or may be received indirectly via one or more intermediary computing devices, such as, for example, one or more servers, relays, routers, network access points, base stations, hosts, and/or the like, sometimes referred to herein as a“network.”
  • intermediary computing devices such as, for example, one or more servers, relays, routers, network access points, base stations, hosts, and/or the like, sometimes referred to herein as a“network.”
  • the data may be sent directly to the another computing device or may be sent indirectly via one or more intermediary computing devices, such as, for example, one or more servers, relays, routers, network access points, base stations, hosts, and/or the like.
  • client device refers to computer hardware and/or software that is configured to access a service made available by a server.
  • the server is often (but not always) on another computer system, in which case the client device accesses the service by way of a network.
  • Client devices may include, without limitation, smart phones, tablet computers, laptop computers, wearables, personal computers, enterprise computers, and the like.
  • the term“user” should be understood to refer to an individual, group of individuals, business, organization, and the like; the users referred to herein are accessing a group-based communication or messaging system using client devices.
  • the terms“profile,”“account,” and“account details” refer to information associated with a user (e.g., patient, provider, lab, payer, etc.), including, for example, a user identifier, an email address, a real name (e.g., John Doe), a username (e.g., jdoe), a password, a time zone, a status, and the like.
  • the account details can include a subset designation of user credentials, such as, for example, login information for the user including the user’s username and password.
  • a profile identifier refers to any data that identifies a user.
  • a profile identifier may include a unique identifier, an IP address, a MAC address, ASCII text, a pointer, a memory address and the like.
  • profile data refers to any data associated with a profile identifier, such as, but not limited to, biographical data or any other data that may serve to characterize or describe the associated user.
  • biographical data refers to information associated with a person(s) identified in a profile, such as, for example, birth dates, allergies, socio-economic data, place of residence, login credential information, and/or any other identifying information about a profile.
  • the term“lab request” refers to any electronically generated digital content that is an instruction or direction, generally initiated by a user, for a medical test to be performed.
  • the lab request can include an order for a medical test to be performed by a laboratory (e.g., a research or clinical laboratory).
  • the lab request may order a specific medical test, one or more medical tests, a series of medical tests, or combinations thereof.
  • the lab request may include an order for a specific laboratory to perform the medical test or may not specify the laboratory to perform the medical test.
  • the lab request may include a variety of information such as identifying information regarding the patient and/or provider initiating the lab request and identifying information regarding the medical test requested.
  • Lab code refers to an identifier associating one or more medical tests ordered in a lab request with a lab fee for the one or more medical tests to be performed.
  • A“lab code indication” refers to any electronically generated digital content that includes a lab code.
  • Lab fee indication refers to any electronically generated digital content that is an indication indicating a monetary amount identified for performance of one or more medical tests (“lab fee”) ordered in a lab request.
  • Lab request initiator refers to the entity ordering the one or more medical tests listed in a lab request.
  • the lab request initiator may be a client device operated by a physician, hospital, clinic, research facility, etc.
  • One or more lab request initiator may be associated with a lab request. That is, a lab request may group medical tests together over more than one lab request initiator.
  • Lab results are associated with a lab request and refers to any electronically generated digital content that represent medical test results obtained from performance of one or more of the medical tests ordered in the associated lab request.
  • Lab results indication refers to any electronically generated digital content that is an indication indicating that lab results have been obtained and may include the lab results.
  • the lab request indication will include the lab results.
  • the lab request indication may include all supporting documentation (e.g., the genomic file).
  • Lab instructions refers to any electronically generated digital content that is an indication typically provided to a laboratory (e.g., clinical or research laboratory) that sets forth one or more medical tests to be performed.
  • the lab instructions may include a variety of information such as requested date of completion, patient data, provider data, payer data, etc. as discussed herein.
  • the lab instructions may include any information that may help enable the receiving laboratory to perform one or more of the medical tests indicated in the lab instructions.
  • Lab payment refers to a monetary disbursement intended to compensate the direct or indirect receiver of the lab payment for performance of one or more medical tests ordered in the lab request associated with the lab payment.
  • Lab payment indication refers to any electronically generated digital content that is an indication indicating that lab payment will be provided or is provided. That is, the lab payment indication may include the lab payment or indicate that payment will be provided at a later date. That is, the lab payment indication may include payment details relating to a past, concurrent, or planned future payment for the one or more medical tests.
  • Lab request denial is associated with a lab request and refers to any electronically generated digital content that is an indication that one or more medical tests ordered in the associated lab request should not be ordered. For instance, in some embodiments, a lab request denial may be generated in response to the determination that the associated patient’s insurance policy may not or will not cover one or more medical tests ordered in the associated lab request.
  • the lab clearinghouse device may provide the lab request denial in real-time to the lab request initiator (e.g., the ordering physician). That is, prior to execution or performance of the medical tests requested in the lab request (and prior to generation and transmission of lab instructions), the lab request may be analyzed and a lab request denial may be generated and transmitted to the lab request initiator.
  • the phrase“suggested revised lab request” refers to any electronically generated digital content that is an instruction or direction, generally initiated by a user, for a medical test to be performed.
  • the suggested revised lab request may include suggested revised medical laboratories, suggested revised medical tests, or combinations thereof that are suggested to replace or supplement the original medical laboratories or medical tests listed in a prior lab request.
  • A“laboratory” can be a medical/clinical laboratory, research laboratory, pathologist, outpatient hospital, physician office, or the like.
  • “Revised lab request” refers to any modified electronically generated digital content that is an instruction or direction, generally initiated by a user, for a medical test to be performed and is generally generated in response to a lab request denial of a prior lab request.
  • the revised lab request can include an order for one or more medical tests to be performed by a laboratory (e.g., a research or clinical laboratory).
  • the revised lab request may order a specific medical test, one or more medical tests, a series of medical tests, or combinations thereof.
  • the revised lab request may include an order for a specific laboratory to perform the medical test or may not be specific to the laboratory for performing the medical test.
  • the revised lab request may include a variety of information such as identifying information regarding the patient and/or provider initiating the lab request and identifying information regarding the medical test requested.
  • Communications such as lab requests, lab code indication, lab fee indications, lab results, lab results indication, lab instructions, lab payment, lab payment indications, lab request denial, revised lab request, warning indications, etc. may include any text, image, video, audio, or combination thereof provided by a user (using a client device).
  • the user may provide a communication that includes text as well as an image and a video within the communication as communication contents.
  • the text, image, and video would comprise the communication or digital content object.
  • Each communication sent in the lab clearinghouse system may include metadata comprising the following: a sending user identifier and communication contents.
  • the sending user identifier and the communication contents may be represented by ASCII text, a pointer to a memory address, a hyperlink, or the like.
  • the communications may also include information related to the user who created the communication, the client device on which the communication was first provided or is associated with, the time and date that the communication was first provided, additional communications stemming from the communication, and any other identifying information related to the communication.
  • A“sending user identifier” is associated with a communication that is sent by a particular user (i.e., a client device associated with the particular user).
  • the sending user identifier may be analyzed to determine context regarding the user (e.g., patterns associated with the user).
  • pre-established data includes data associated with patients, laboratories, medical providers (e.g., physicians), lab payers, and combinations thereof that has been collected outside of the lab request.
  • the pre-established data is data obtained prior to receipt of the lab request or after receipt of the lab request.
  • Pre-established data may include historical data concerning one or more patients, laboratories, medical providers, and lab payers.
  • Pre-established data may include data across one or more patients, laboratories, medical providers, and lab payers.
  • Pre-established data may include historical data, genomic data, persistent data, profile data, location data, pricing data, or combinations thereof associated with a single patient, laboratory, medical provider, or lab payer, or across multiple patients, laboratories, medical providers, lab payers, or combinations thereof.
  • Pre- established data may form a pre-established practice which refers to a series of one or more medical tests, lab requests, etc. that share common considerations (e.g., diagnoses) and share a common result (e.g., ordered medical tests).
  • A“warning indication” refers to any electronically generated digital content that indicates that fraud, waste, abuse, or combinations thereof may be associated with the associated lab request.
  • the lab clearinghouse device may determine that one or more of fraud, waste, or abuse may be likely for one or more medical tests ordered in the lab request.
  • a warning indication may then be generated and transmitted in response to the appropriate entity, for example, the patient (via a client device), laboratory 110C, lab payer 110B, medical provider 110A, etc.
  • A“request for additional data” which may be specific to the type of data requested (e.g., a“request for additional patient data”, a“request for additional physician data”, etc.) refers to any electronically generated digital content that requests additional information regarding a lab request (e.g., additional information regarding the implicated patient, laboratory, medical provider, lab payer, etc.). The additional information may be used in determining whether fraud, waste, or abuse are likely with regards to one or more medical tests ordered in the lab request.
  • A“degree of quality” refers to a determination of the condition or superiority of as associated element.
  • a degree of quality as used herein will refer to the determination of the quality of an associated medical test that may be performed by a laboratory.
  • the degree of quality may be specific to the medical test and to the laboratory performing the medical test or may be specific to only the medical test (regardless of the laboratory that performs the medical test) or only the laboratory (regardless of the medical test that the laboratory is to perform).
  • Various embodiments of the invention are directed to systems, methods, devices, and computer program products that are configured to efficiently process laboratory orders, results, and payments within a defined system across medical laboratories, lab payers, and medical providers.
  • Lab Clearinghouse Device and Pricing Structure Provided herein are systems, methods, devices, and computer program products to manage lab requests and lab payments.
  • a lab clearinghouse device is designed to be the intermediary in transmissions between patients, providers (e.g., physicians, hospitals, etc.), lab payers, and laboratories, and as a result, the lab clearinghouse device has access to information, e.g., electronic medical records, from each of these entities.
  • the lab clearinghouse device may provide real-time decision support integrations with the ordering provider (e.g., individual physician, physician group, hospital) workflow and may provide real-time adjudication of a lab request.
  • the lab clearinghouse device may adjudicate the lab request in real-time based on information received from the provider, the member (e.g., patient), the lab payer, and any contract with the lab to perform the medical tests ordered in the lab request.
  • the lab clearinghouse device will eliminate the need for laboratories to create insurance claims for payment, or for lab payers to adjudicate such insurance claims.
  • the lab clearinghouse device may generate a lab fee indication indicating that payment for one or more medical tests is needed. Payment of the medical tests may be requested, agreed to, and may be required prior to the lab clearinghouse device initiating transmission of lab instructions for performance of the medical tests by a lab.
  • lab payers and laboratories may realize reduced costs and increased efficiency due to the removal of the need to create insurance claims.
  • lab payers and medical providers may have access to data (e.g., detailed and complex test results) through the lab clearinghouse device that may otherwise not be readily accessible.
  • Laboratories may experience an increase in revenue due to the payment of lab payer liability (e.g., member liability) prior to performance of the medical tests and may have less administrative costs due to the removal of the claims processing system.
  • High-deductible health plans are increasing in popularity. These plans place more liability on the patient. Such liability is difficult and costly for the laboratories to track down and successfully obtain.
  • a lab clearinghouse device as described herein, liability is established and resolved prior to performance of the medical tests by the laboratory. By conditioning performance of the laboratory work on payment or agreement to payment, laboratories may experience an increase in payments received and a concomitant decrease in the overhead associated with debt collection.
  • the lab clearinghouse device may be able to communicate with electronic medical records (e.g., HL7 ORU (results) and REST API), with billing systems (e.g., payments (EFT/checks)) for on-premise laboratories, payers (e.g., invoices and encounters, pre authorization EDI 278), and laboratories (e.g., HL7 OBM (order) and HL7 ORU (results), and payments (EFT/checks)).
  • EFT/checks payments
  • the lab clearinghouse device allows for shifting of the price structure away from claims-based payment adjudication that prices large groups of tests under broad claims to a model that prices medical tests based on the individual requirements of the medical tests themselves.
  • medical tests may be priced based on the underlying data regarding the lab request (e.g., patient, laboratory, etc.) rather than the insurance claim that results from a lab request.
  • the lab request e.g., patient, laboratory, etc.
  • use of a lab clearinghouse device as described herein enables medical tests to be priced based on the actual needs of the patient.
  • denial of payment by insurance companies due to ineligible tests, clinical editing, duplicate tests, etc. can be avoided on the front end.
  • the lab clearinghouse device may be configured to adjudicate lab requests (e.g., analysis, approval/denial, payment, etc.) and provide relevant information to the appropriate parties (e.g., laboratories, payers, medical providers, etc.) efficiently and effectively.
  • the manner by which the lab clearinghouse device provides adjudication of lab requests is rooted in computer technology in order to overcome a problem specifically arising in the realm of computer networks.
  • current systems for adjudicating payment of lab requests operates in a disjointed fashion in which various component nodes within an interconnected system (i.e., medical providers, laboratories, and payers such as insurance companies) have access to different subsets of information.
  • Producing gains in efficiency, speed, or resource allocation thus requires these entities to employ sophisticated software and computer tools to account for the information not known to them a priori.
  • a medical provider is able to determine what medical tests may be required to provide appropriate care to a given patient, but is often unable to determine whether the medical test would be covered by the patient’s insurance carrier.
  • a laboratory may be unable to determine whether the requested medical tests are covered by the patient’s insurance, and may thus be forced to employ sophisticated software tools to evaluate the patient’s ability to pay for the medical tests should the insurer not cover it.
  • insurance companies may not have access to the requested medical tests and rather, simply see the resulting claims, and may thus be forced to employ sophisticated software tools to evaluate whether the claims are covered by the patient’s policy.
  • the lab clearinghouse device may allow for less strain on the systems of the medical providers, laboratories, and lab payers leading to increased system efficiency. Due to the removal of the need to create and submit claims, this effect is particularly amplified for laboratories and lab payers.
  • the lab clearinghouse device may also allow for reduced network traffic and data processing on the part of the various entities with which it interacts by removing the need to create and submit claims (e.g., intermediary systems, collection agencies, and the like).
  • medical tests may be priced more specifically (rather than being grouped with lOO’s of other labs and priced with those other labs), thereby reducing costs for the lab payer and the patient (e.g., due to reduced denials).
  • the lab clearinghouse device may also increase provider engagement as the provider communicates with the lab clearinghouse device to determine the lab request (e.g., through suggested revised lab requests and revised lab requests).
  • patients may have had difficulty accessing lab results.
  • patients may receive lab results via the lab clearinghouse device, directly or indirectly, and may no longer need to track down lab results directly from corresponding providers or laboratories (with whom the patient may never have previously interacted).
  • the lab clearinghouse device may be used as part of a standalone service, application, or device or it may be applied as a layer atop an existing service application or device.
  • a lab clearinghouse device is designed to be the intermediary in transmissions between patients, providers (e.g., physicians, hospitals, etc.), lab payers, and laboratories, and as a result, the lab clearinghouse device has access to information, e.g., electronic medical records, from each of these entities.
  • the lab clearinghouse device may provide real-time decision support integrations with the ordering provider (e.g., individual physician, physician group, hospital, clinic, etc.) workflow, may provide real-time analysis of a lab request based on information received from the provider, member (e.g., patient), lab payer, and laboratory, and may contract with the laboratory to perform the medical tests ordered in the lab request.
  • the lab clearinghouse system may include a lab clearinghouse device.
  • the lab clearinghouse device may include a lab results feedback loop that may collect genomic information as well as other persistent and historical data.
  • the lab clearinghouse device can be used for learning and predictive analytics (e.g., prevalence of diseases based on specific genome markers). De-identified data can be sold to life sciences organizations.
  • the lab clearinghouse device can be used to trim the volume of future lab work, thus increasing the efficiency and effectiveness of the lab clearinghouse system compared to current practices.
  • redundant or unnecessary labs can be avoided (e.g., by offering the results of a prior medical test instead of ordering a new medical test, warning the lab request initiator that the medical test was previously performed, or enabling the physician to see previously ordered medical tests for a specific patient).
  • the lab clearinghouse system can thereby avoid waste, reducing costs for patients, providers, laboratories, and lab payers. Denial of payment by insurance companies due to redundant or duplicate tests can be avoided on the front end with the use of the lab clearinghouse device.
  • the frequency of a medical test ordered by one physician for a certain population can be compared to other ordering physicians to identify - and thus avoid - abuse.
  • the lab clearinghouse device can also avoid fraud (e.g., by matching the ordering physician or patient against a death file).
  • lab results may be provided to lab payers as well as medical providers.
  • the lab clearinghouse device may help reduce the effort associated with capturing supplemental data required for HEDIS and STARS.
  • the lab clearinghouse device may generate a lab fee indication indicating that payment for one or more medical tests is needed. Payment for the medical tests may be made, and in some embodiments, such payment may be required prior to the lab clearinghouse device initiating lab instructions associated with the underlying lab request for performance of the medical tests.
  • the lab clearinghouse device may allow for more accurate lab ordering, thereby reducing costs to patients, laboratories (e.g., laboratories are more likely to be reimbursed for performance of the medical tests), lab payers, and medical providers.
  • the lab clearinghouse device may have access to a variety of information concerning patients, laboratories, lab payers, and medical providers and is thereby able to more accurately evaluate and determine whether fraud, waste, and/or abuse are likely with regards to the medical tests requested in lab requests.
  • the lab clearinghouse device may have access to both a lab request, specifying one or more medical tests to be performed, lab instructions, and lab results.
  • the lab clearinghouse device can evaluate whether fraud, waste, and/or abuse are likely with regards to the medical tests, and then, after communicating with the lab request initiator in some embodiments, generate and transmit lab instructions tailored to the lab request and associated data.
  • the lab clearinghouse device may edit the lab request (e.g., through a lab request denial that provides a suggested revised lab request or through a request for additional data).
  • the lab clearinghouse device may receive lab results thereby allowing the lab clearinghouse device to evaluate - after the fact - whether fraud, waste, and/or abuse are likely with regards to the medical tests, which can be used in determining whether fraud, waste, and/or abuse are likely with regards to future medical tests and to further tailor the lab requests and lab instructions.
  • the lab clearinghouse device may thereby reduce fraud, waste, and abuse.
  • a lab payer may not fully understand the medical tests performed by a laboratory and typically will not have access to the provider’s original order, which may lead to the lab payer inaccurately deciding to pay or not pay for a medical test or paying for more or less than what was originally requested.
  • a laboratory may not fully understand the medical tests requested by a provider which may lead to the laboratory performing more medical tests, fewer medical tests, or inappropriate medical tests.
  • the lab clearinghouse device may reduce issues associated with lab payers and laboratories not fully understanding the medical tests requested. For instance, the lab clearinghouse device may be able to identify when lab instructions were not followed or when lab payments were inaccurately withheld or made.
  • the lab clearinghouse device may have access to information specifically concerning patients across a variety of laboratories, providers, and lab payers.
  • the lab clearinghouse device may thereby be able to identify inappropriate or redundant medical tests requested for the patient.
  • the lab clearinghouse device may be configured to determine whether fraud, waste, and/or abuse are likely with regards to the medical tests prior to execution of the medical tests requested in the lab request or performance of the medical tests requested in the lab request. This proactive system may reduce fraud, waste, and abuse, thereby reducing costs and increasing efficiency.
  • the lab clearinghouse device is rooted in computer technology in order to overcome a problem specifically arising in the realm of computer networks (e.g., lack of communication or miscommunication and mishandling of medical tests across multiple client devices and servers).
  • current systems for reducing fraud, waste, and abuse operate in a disjointed fashion in which various component nodes within an interconnected system (i.e., medical providers, laboratories, and payers such as insurance companies) have access to different subsets of information.
  • a medical provider is able to determine what medical tests may be required to provide appropriate care to a given patient, but is often unable to determine whether that medical test or a medical test providing comparable results has been performed on the patient in the past regardless of where the medical test was performed.
  • a laboratory may be unable to determine whether the requested medical tests is redundant or excessive, and may thus be forced to employ sophisticated software tools to evaluate whether the medical test will likely be deemed redundant or excessive and not paid for by the lab payer.
  • the lab clearinghouse device may in many embodiments also reduce the strain on the systems of the medical providers, laboratories, and lab payers (e.g., due to more appropriate medical testing), leading to increased adjudicatory speed and efficiency.
  • the lab clearinghouse device may also reduce network traffic and data processing requirements by centralizing data analysis and shifting the evaluation of the lab request to the front end prior to execution or performance of the medical tests.
  • the lab instructions may be more accurately tailored to the needs of the patient and provider, thereby reducing costs for the lab payer and the patient (e.g., by reducing denials) and for the laboratories (e.g., by avoiding redundant or excessive testing or non-reimbursable testing).
  • the lab clearinghouse device may also increase provider engagement as the provider communicates with the lab clearinghouse device to determine the lab request (e.g., through suggested revised lab requests and revised lab requests).
  • the lab clearinghouse device is designed to be the intermediary in transmissions between patients, providers (e.g., physicians, hospitals, etc.), lab payers, and laboratories and as a result, the lab clearinghouse device has access to information, e.g., electronic medical records, from each of these entities.
  • the lab clearinghouse device may provide real-time decision support integrations with the ordering provider (e.g., individual physician, physician group, hospital, clinic, etc.) workflow, may provide real-time analysis of a lab request, and contract with the laboratory to perform the medical tests ordered in the lab request.
  • the lab clearinghouse system may include a lab clearinghouse device.
  • the lab clearinghouse device may manage a network of laboratories and take on risk or engage in a risk sharing arrangement with lab payers.
  • the lab clearinghouse device would have centralized information regarding the patient, laboratories, providers, lab payers, etc., that it can use to process authorizations for lab requests and the medical tests requested therein. With the centralized information, the lab clearinghouse device can more effectively manage the lab requests - requesting the right lab for the right patient at the right time - and better anticipate payments and take on risk of payment by the lab payer (e.g., the patient, member, and/or insurance carrier).
  • the lab clearinghouse device may evaluate the appropriateness of the lab request and thereby determine whether the right lab for the right patent at the right time is requested.
  • Machine learning models can be used to automate authorization of lab requests. Also, medical testing can be steered to more appropriate laboratories (e.g., in-network laboratories) thereby reducing costs and increasing efficiencies. The lab request may be evaluated in real-time thereby avoiding denials after performance of the medical tests.
  • the lab clearinghouse device may evaluate the appropriateness of the lab request by analyzing patient data, such as clinical results from the patient’s medical history, and determine whether the medical tests ordered in the lab request are appropriate based on this patient data. For instance, the lab clearinghouse device may determine that based on the diagnosis of the patient, a different medical test may be more appropriate than the medical tests requested in the lab request and may be more likely to be covered by the patient’s insurance carrier and/or the patient.
  • the lab clearinghouse device may communicate with the provider (via a client device) to revise the lab request accordingly.
  • the lab clearinghouse device has access to the details of the lab request (e.g., the medical tests requested, information regarding the lab request initiator, etc.) as well as historical information concerning the patient, member, lab payer, provider, and laboratories.
  • the lab clearinghouse device is able to evaluate the appropriateness of the lab request based on this information and then generate lab instructions once the appropriateness of the lab request is confirmed.
  • the lab instructions are more tailored to the information desired in the lab request and more tailored to the patient, member, provider, lab payer, and laboratory affected resulting in more useful lab results for patients and providers, reduced costs, reduced denials by lab payers, increased reimbursements to laboratories, and various other benefits.
  • the lab clearinghouse device can also beneficially perform this evaluation on the front-end prior to execution or performance of the medical tests, thereby avoiding excessive costs and later denials.
  • the lab clearinghouse device may generate lab instructions and direct such instructions to a specific laboratory. Based on a review of the various information to which the lab clearinghouse device is privy, the lab clearinghouse device may determine which laboratory (e.g., across cities, states, regions, technologies, fees, timeliness, etc.) that may be more appropriate for performing the medical tests requested in the lab request. When determining the appropriateness of the lab request, the lab clearinghouse device may determine the appropriateness of the laboratory listed in the lab request and suggest a different laboratory should the laboratory be deemed not as appropriate as another laboratory. The appropriateness may consider the location, cost, quality, timeliness, etc. of the laboratory.
  • the lab clearinghouse device may generate a lab fee indication indicating that payment for one or more medical tests is needed. Payment for the medical tests may be made, and in some embodiments, such payment may be required prior to the lab clearinghouse device generating and transmitting lab instructions associated with the underlying lab request for performance of the medical tests.
  • the lab clearinghouse device may allow for more accurate lab ordering, thereby reducing costs to patients, laboratories (e.g., laboratories are more likely to be fully reimbursed for performance of the medical tests), lab payers, and medical providers.
  • the lab clearinghouse device may have access to a variety of information concerning patients, laboratories, lab payers, and medical providers and is thereby able to more accurately evaluate and determine whether the medical tests requested in the lab requests are appropriate.
  • the lab clearinghouse device may have access to both the lab request, specifying one or more medical tests to be performed, lab instructions, and lab results.
  • the lab clearinghouse device can evaluate whether the one or more medical tests are appropriate, and then, after communicating with the lab request initiator in some embodiments, generate and transmit lab instructions tailored to the lab request and associated data.
  • the lab clearinghouse device may edit the lab request (e.g., through a lab request denial and suggested revised lab request or through a request for additional data).
  • the lab clearinghouse device analyzes the lab requests; can communicate with the lab request initiator; has access to data concerning patients, laboratories, lab payers, and medical providers and can communicate with each of these parties (via a client device); and generates and transmits the lab instructions, the lab clearinghouse device may ensure the right medical test was requested for the right patient at the right time.
  • the lab clearinghouse device may have access to information specifically concerning laboratories across a variety of patients, providers, and lab payers.
  • the lab clearinghouse device may thereby be able to identify laboratories for performing one or more of the medical tests requested in a lab request and include such laboratory in the lab instructions.
  • the lab clearinghouse device may identify a laboratory in the network of the lab payer, a laboratory with lower fees, a laboratory with a high degree of quality, a laboratory in a location convenient to the patient and/or provider, or laboratories with various other considerations that suggest the laboratory should be used for performance of the requested medical tests.
  • the lab clearinghouse device may have access to information specifically concerning lab payers across a variety of patients, providers, and laboratories.
  • the lab clearinghouse device may have access to information specifically concerning patients across a variety of laboratories, providers, and lab payers.
  • the lab clearinghouse device may thereby be able to identify errors in the medical tests requested for the patient.
  • the lab clearinghouse device may be configured to determine the appropriateness of the lab request and based on the appropriateness, approve or deny the lab request, thereby reducing costs and increasing efficiency.
  • the lab clearinghouse device is rooted in computer technology in order to overcome a problem specifically arising in the realm of computer networks (e.g., lack of communication or miscommunication and mishandling of medical tests across multiple parties).
  • current systems for pre-authorization of medical claims operate in a disjointed fashion in which various component nodes within an interconnected system (i.e., medical providers, laboratories, and payers such as insurance companies) have access to different subsets of information.
  • these entities have to employ sophisticated software and computer tools to account for the information not known to them a priori.
  • a medical provider is able to determine what medical tests may be required to provide care to a given patient, but is often unable to determine whether the medical laboratory is covered by the patient’s insurance policy or whether another laboratory would be cheaper, provide higher quality results, or provide more appropriate medical testing.
  • a laboratory may be unable to determine whether the requested medical tests is covered by a patient’s insurance policy, and may thus be forced to employ sophisticated software tools to evaluate whether the medical test will likely be paid for by the lab payer.
  • insurance companies may not have access to the requested medical tests and rather, simply see the resulting claims from the laboratories, and may thus be forced to employ sophisticated software tools to evaluate whether the correct medical tests were performed and reported. More appropriate medical testing or more appropriate laboratories may still be missed.
  • the lab clearinghouse device may allow for less strain on the systems of the medical providers, laboratories, and lab payers (e.g., due to more appropriate medical testing) leading to increased lifetime and efficiency.
  • the lab clearinghouse device may also reduce network traffic and data processing by shifting the evaluation of the lab request to the front end prior to execution or performance of the medical tests.
  • the medical tests may be more accurately tailored to the needs of the patient and provider thereby reducing costs for the lab payer and the patient (e.g., due to reduced denials) and for the laboratories (e.g., due to reduced inappropriate testing).
  • the lab clearinghouse device may also increase provider engagement as the provider communicates with the lab clearinghouse device to determine an appropriate lab request (e.g., through suggested revised lab requests and revised lab requests). Medical tests may vary across laboratories.
  • the lab clearinghouse device may allow for modification of lab requests to specify more appropriate laboratories (e.g., based on cost, quality, timeliness, etc.) for performance of the medical tests.
  • the lab clearinghouse device may avoid a significant manual effort seen in current systems. Physicians usually have to gather data and send data to the lab payer (e.g., by fax or electronically) in support of a requested lab. On the lab payer side, a party has to review the submitted documentation to validate that the lab can be authorized.
  • the lab clearinghouse device may be able to communicate immediately to the physician that the request requires certain information and may provide feedback to the physician in real-time.
  • Methods, devices, and computer program products of the present invention may be embodied by any of a variety of devices.
  • the method, device, and computer program product of an example embodiment may be embodied by a networked device (e.g., an enterprise platform), such as a server or other network entity, configured to communicate with one or more devices, such as one or more client devices.
  • the computing device may include fixed computing devices, such as a personal computer or a computer workstation.
  • example embodiments may be embodied by any of a variety of mobile devices, such as a portable digital assistant (PDA), mobile telephone, smartphone, laptop computer, tablet computer, wearable, or any combination of the aforementioned devices.
  • PDA portable digital assistant
  • FIG. 1 shows lab clearinghouse system 100 including an example network architecture for a system, which may include one or more devices and sub-systems that are configured to implement some embodiments discussed herein.
  • lab clearinghouse system 100 may include lab clearinghouse device 120, which can include, for example, the circuitry disclosed in FIGS. 2 -4c, one or more client devices, one or more servers, or database, among other things (not shown).
  • the lab clearinghouse device 120 may include any suitable network server and/or other type of processing device.
  • the lab clearinghouse device 120 may receive lab requests, revised lab requests, lab payments, etc. and generate and transmit warning indications, requests for additional data, lab instructions, lab fee indications, lab code indications, suggested revised lab requests, etc.
  • the lab clearinghouse data store 300 may be embodied as a data storage device such as a Network Attached Storage (NAS) device or devices, as a separate database server or servers (e.g., cloud computing), or distributed across multiple devices in a network (e.g., block chain).
  • the lab clearinghouse data store 300 stores information for the lab clearinghouse device 120 to facilitate the operations of the lab clearinghouse system 100.
  • the lab clearinghouse data store 300 may include, without limitation, a plurality of data regarding patients, medical tests, laboratories, medical providers, lab payers, etc., organized within the lab clearinghouse data store 300.
  • Lab clearinghouse device 120 can communicate with one or more medical providers 110A, laboratories 110C, and lab payers 110B, each of which may include one or more client devices and/or servers, via network 140.
  • network 140 may include any wired or wireless communication network including, for example, a wired or wireless local area network (LAN), personal area network (PAN), metropolitan area network (MAN), wide area network (WAN), or the like, as well as any hardware, software and/or firmware required to implement it (such as, e.g., network routers, etc.).
  • network 140 may include a cellular telephone, an 802.11, 802.16, 802.20, and/or WiMax network.
  • the network 140 may include a public network, such as the Internet, a private network, such as an intranet, or combinations thereof, and may utilize a variety of networking protocols now available or later developed including, but not limited to TCP/IP based networking protocols.
  • the networking protocol may be customized to suit the needs of the lab clearinghouse device 120 and/or lab clearinghouse system 100.
  • the lab clearinghouse device 120 may provide for receiving of electronic data from various sources, including but not necessarily limited to one or more medical providers
  • the lab clearinghouse device 120 may be operable to receive and post or transmit communications provided by the one or more medical providers 110A, laboratories 110C, and lab payers 110B.
  • Lab clearinghouse device 120, medical providers 110A, laboratories 110C, and lab payers 110B may each be implemented as a personal computer and/or other networked device, such as a cellular phone, tablet computer, mobile device, desktop computer, laptop computer, smartphone, netbook, wearable, and the like, that may be used for any suitable purpose in addition to processing lab requests, lab results, and lab payments etc.
  • the depiction in FIG. 1 of one medical provider 110A, one lab payer 110B, and one laboratory 110C is merely for illustration purposes. Any number of medical providers 110A, lab payers
  • I IOB, and laboratories 110C may be included in the lab clearinghouse system 100.
  • the medical providers 110A, lab payers 110B, and laboratories 110C may be configured to display an interface on a display of the respective device for viewing, creating, editing, and/or otherwise interacting with lab clearinghouse device 120.
  • the lab clearinghouse device 120 may be configured to display an interface on a display of the lab clearinghouse device 120 for viewing, creating, editing, and/or otherwise interacting with the medical providers 110A, lab payers 110B, and laboratories 110C.
  • an interface of a medical provider 110A, lab payer 110B, and laboratory 110C may be the same or different from an interface of a lab clearinghouse device 120.
  • Lab clearinghouse system 100 may also include additional client devices and/or servers, among other things. Additionally or alternatively, the lab clearinghouse device 120, medical providers 110A, lab payers 110B, and laboratories 110C may interact within the lab clearinghouse system 100 via a web browser. As yet another example, the lab clearinghouse device 120, medical providers 110A, lab payers 110B, and laboratories 110C may include various hardware or firmware designed to interface with the various other devices within the lab clearinghouse system 100.
  • the lab clearinghouse device 120, medical providers 110A, lab payers 110B, and laboratories 110C may be any computing device as defined above. Electronic data received by the lab clearinghouse device 120 from the medical providers 110A, lab payers 110B, and laboratories 110C may be provided in various forms and via various methods. Electronic data received by the medical providers 110A, lab payers 110B, and laboratories 110C from the lab clearinghouse device 120 maybe provided in various forms and via various methods.
  • the lab clearinghouse device 120 may be able to communicate with electronic medical records (e.g., HL7 ORU (results) and REST API), with billing systems (e.g., payments (EFT/checks)) for on-premise laboratories, payers (e.g., invoices and encounters, pre-authorization EDI 278), and laboratories (e.g., HL7 OBM (order) and HL7 ORU (results), and payments (EFT/checks)).
  • electronic medical records e.g., HL7 ORU (results) and REST API
  • billing systems e.g., payments (EFT/checks)
  • payers e.g., invoices and encounters, pre-authorization EDI 278
  • laboratories e.g., HL7 OBM (order) and HL7 ORU (results), and payments (EFT/checks)
  • any of the lab clearinghouse device 120, medical provider 110A, lab payer 110B, and laboratory 110C is a mobile device, such as a smart phone or tablet
  • the respective client device may execute an“app” to operate within the lab clearinghouse system 100.
  • apps are typically designed to execute on mobile devices, such as tablets or smartphones.
  • an app may be provided that executes on mobile device operating systems such as iOS®, Android®, or Windows®.
  • These platforms typically provide frameworks that allow apps to communicate with one another and with particular hardware and software components of mobile devices.
  • the mobile operating systems named above each provide frameworks for interacting with location services circuitry, wired and wireless network interfaces, user contacts, and other applications. Communication with hardware and software circuitries executing outside of the app is typically provided via application programming interfaces (APIs) provided by the mobile device operating system.
  • APIs application programming interfaces
  • lab clearinghouse device 120 may interact with other devices within the lab clearinghouse system 100 via a web browser.
  • a communication (e.g., a lab request, lab instructions, lab fee indication, lab payment indication, lab request denial, warning indication, request for additional data, patient data, provider data, physician data, payer data, etc.) may be sent from a medical provider 110A, lab payer 110B, and/or laboratory 110C to a lab clearinghouse device 120.
  • the communication may be sent directly to the lab clearinghouse device 120 (e.g., via a peer-to-peer connection) or over a network 140 , in which case the communication may in some embodiments be transmitted via an intermediary such as a message server, and/or the like.
  • the communication may include data such as a sending user identifier, communication contents (e.g., text, emojis, images, links), attachments (e.g., files), communication hierarchy data (e.g., whether the communication is a reply to another communication), metadata, and/or the like.
  • data such as a sending user identifier, communication contents (e.g., text, emojis, images, links), attachments (e.g., files), communication hierarchy data (e.g., whether the communication is a reply to another communication), metadata, and/or the like.
  • the lab clearinghouse system 100 may include a server (e.g., as part of the lab clearinghouse device 120) that may store communications, which may be indexed, in a lab clearinghouse data store 300.
  • a storage communication may be generated and stored in remote storage (e.g., cloud storage).
  • the storage communication may include data such as a sending user identifier, communication contents, attachments, message hierarchy data, metadata, and/or the like.
  • the communication may be parsed by the lab clearinghouse device 120 to identify various components included therein. Parsing of the communication may facilitate determination by the lab clearinghouse device 120 of a sending user identifier of the user who sent the message and/or to the contents of the communication and to what or whom the communication relates. Similarly, parsing of the communication enables the lab clearinghouse device 120 to determine topics discussed in the message (e.g., medical tests, lab results, lab payments, lab codes, lab fees, etc.). In another example, the communication may be analyzed (e.g., by itself, or with other communications) or parsed using a machine learning technique, such as topic modeling, to determine topics associated with the message. The topics may help provide context for the communication such that the lab clearinghouse device 120 and other components of the lab clearinghouse system 100 may generate an appropriate response.
  • a machine learning technique such as topic modeling
  • attachments may be included with the communication. If there are attachments, files may be associated with the communication. In one implementation, the communication may be parsed to determine information regarding the attachments, such as file names and contents, which may in turn be analyzed to determine the context of the communication (e.g., to determine whether the communication relates to a lab fee, lab payment, lab results, etc.).
  • Metadata may be associated with the communication.
  • metadata may provide additional context regarding the communication or the user that is specific to a company, organization, and/or the like.
  • the communication may be parsed to determine metadata.
  • metadata may provide data regarding the user who sent the communication.
  • various metadata, determined as described above, and/or the contents of the communication may be used to index the communication to facilitate various facets of searching (i.e., search queries that return results from lab clearinghouse data store 300).
  • a communication may be sent from lab clearinghouse device 120 to facilitate indexing in the lab clearinghouse data store 300.
  • metadata associated with the communication may be determined and the communication may be indexed in the lab clearinghouse data store 300.
  • the communication may be indexed such that an entity’s communications are indexed separately (e.g., in a separate index associated with the patient, medical provider, laboratory, lab payer, etc. that is not shared with other patients, medical providers, laboratories, lab payers, etc.).
  • communications may be indexed at a separate distributed database (e.g., to facilitate data isolation for security purposes).
  • file contents of the associated files may be used to index such files in the lab clearinghouse data store 300 to facilitate searching.
  • the files may be indexed such that files for a patient, medical provider, laboratory, lab payer, etc. are indexed at a separate distributed database.
  • FIG. 2 shows a schematic block diagram of an apparatus 200, some or all of the components of which may be included, in various embodiments, in lab clearinghouse device 120 and/or medical provider 110A, lab payer 110B, and laboratory 110C. Any of the aforementioned systems or devices may include the components of the apparatus 200 and may be configured to, either independently or jointly with other devices in a lab clearinghouse system 100, to perform the functions of the apparatus 200 described herein. As illustrated in FIG. 2, in accordance with some example embodiments, apparatus 200 can includes various means, such as processor 210, memory 220, communications circuitry 230, and/or input/output circuitry 240.
  • lab clearinghouse data store 300 includes lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and lab management circuitry 402 may also or instead be included.
  • circuitry includes hardware, or a combination of hardware with software configured to perform one or more particular functions.
  • the various components of apparatus 200 described herein may be embodied as, for example, circuitry, hardware elements (e.g., a suitably programmed processor, combinational logic circuit, and/or the like), a computer program product comprising computer-readable program instructions stored on a non-transitory computer-readable medium (e.g., memory 220) that is executable by a suitably configured processing device (e.g., processor 210), or some combination thereof.
  • one or more of these circuitries may be hosted remotely (e.g., by one or more separate devices or one or more cloud servers) and thus need not reside on the data set device or user device.
  • the functionality of one or more of these circuitries may be distributed across multiple computers across a network.
  • Processor 210 may, for example, be embodied as various means including one or more microprocessors with accompanying digital signal processor(s), one or more processor(s) without an accompanying digital signal processor, one or more coprocessors, one or more multi-core processors, one or more controllers, processing circuitry, one or more computers, various other processing elements including integrated circuits such as, for example, an ASIC (application specific integrated circuit) or FPGA (field programmable gate array), or some combination thereof. Accordingly, although illustrated in FIG. 2 as a single processor, in some embodiments processor 210 comprises a plurality of processors. The plurality of processors may be embodied on a single computing device or may be distributed across a plurality of computing devices collectively configured to function as apparatus 200.
  • ASIC application specific integrated circuit
  • FPGA field programmable gate array
  • the plurality of processors may be in operative communication with each other and may be collectively configured to perform one or more functionalities of apparatus 200 as described herein.
  • processor 210 is configured to execute instructions stored in memory 220 or otherwise accessible to processor 210. These instructions, when executed by processor 210, may cause the apparatus 200 to perform one or more of the functionalities described herein.
  • processor 210 may comprise an entity capable of performing operations according to embodiments of the present invention while configured accordingly.
  • processor 210 may comprise the specifically configured hardware for conducting one or more operations described herein.
  • processor 210 when processor 210 is embodied as an executor of instructions, such as may be stored in memory 220, the instructions may specifically configure processor 210 to perform one or more algorithms and operations described herein, such as those discussed in connection with FIGS. 5a-8.
  • Memory 220 may comprise, for example, volatile memory, non-volatile memory, or some combination thereof. Although illustrated in FIG. 2 as a single memory, memory 220 may comprise a plurality of memory components. The plurality of memory components may be embodied on a single computing device or distributed across a plurality of computing devices. In various embodiments, memory 220 may comprise, for example, a hard disk, random access memory, cache memory, flash memory, a compact disc read only memory (CD-ROM), digital versatile disc read only memory (DVD-ROM), an optical disc, circuitry configured to store information, or some combination thereof.
  • CD-ROM compact disc read only memory
  • DVD-ROM digital versatile disc read only memory
  • Memory 220 may be configured to store information, data (including item data and/or profile data), applications, instructions, or the like for enabling apparatus 200 to carry out various functions in accordance with example embodiments of the present invention.
  • memory 220 is configured to buffer input data for processing by processor 210.
  • memory 220 is configured to store program instructions for execution by processor 210.
  • Memory 220 may store information in the form of static and/or dynamic information. This stored information may be stored and/or used by the apparatus 200 during the course of performing its functionalities.
  • Communications circuitry 230 may be embodied as any device or means embodied in circuitry, hardware, a computer program product comprising computer readable program instructions stored on a computer readable medium (e.g., memory 220) and executed by a processing device (e.g., processor 210), or a combination thereof that is configured to receive and/or transmit data from/to another device and/or network, such as, for example, a second apparatus 200 and/or the like.
  • communications circuitry 230 (like other components discussed herein) can be at least partially embodied as or otherwise controlled by processor 210.
  • communications circuitry 230 may be in communication with processor 210, such as via a bus.
  • Communications circuitry 230 may include, for example, an antenna, a transmitter, a receiver, a transceiver, network interface card and/or supporting hardware and/or firmware/software for enabling communications with another computing device. Communications circuitry 230 may be configured to receive and/or transmit any data that may be stored by memory 220 using any protocol that may be used for communications between computing devices. Communications circuitry 230 may additionally or alternatively be in communication with the memory 220, input/output circuitry 240 and/or any other component of apparatus 200, such as via a bus.
  • Input/output circuitry 240 may be in communication with processor 210 to receive an indication of a user input and/or to provide an audible, visual, mechanical, or other output to a user (e.g., provider and/or consumer). Some example visual outputs that may be provided to a user by apparatus 200 are discussed in connection with FIGS. 5-8.
  • input/output circuitry 240 may include support, for example, for a keyboard, a mouse, a joystick, a display, a touch screen display, a microphone, a speaker, a RFID reader, barcode reader, biometric scanner, and/or other input/output mechanisms.
  • apparatus 200 is embodied as a server or database
  • aspects of input/output circuitry 240 may be reduced as compared to embodiments where apparatus 200 is implemented as an end- user machine (e.g., lab payer device and/or provider device) or other type of device designed for complex user interactions.
  • input/output circuitry 240 may even be eliminated from apparatus 200.
  • apparatus 200 is embodied as a server or database
  • at least some aspects of input/output circuitry 240 may be embodied on an apparatus used by a user that is in communication with apparatus 200.
  • Input/output circuitry 240 may be in communication with the memory 220, communications circuitry 230, and/or any other component(s), such as via a bus.
  • One or more than one input/output circuitry and/or other component can be included in apparatus 200.
  • Lab clearinghouse data store 300; lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and/or lab management circuitry 402 may also or instead be included and configured to perform the functionality discussed herein related to storing, generating, and/or editing communications.
  • some or all of the functionality of these components of the apparatus 200 may be performed by processor 210, although in some embodiments, these components may include distinct hardware circuitry designed to perform their respective functions.
  • the example processes and algorithms discussed herein can be performed by at least one processor 210, lab clearinghouse data store 300; lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and lab management circuitry 402.
  • non-transitory computer readable media can be configured to store firmware, one or more application programs, and/or other software, which include instructions and other computer-readable program code portions that can be executed to control each processor (e.g., processor 210, lab clearinghouse data store 300; lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and lab management circuitry 402) of the components of apparatus 200 to implement various operations, including the examples shown above.
  • processor 210 e.g., processor 210, lab clearinghouse data store 300; lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and lab management circuitry 402
  • a series of computer-readable program code portions are embodied in one or more computer program goods and can be used, with a computing device, server, and/or other programmable apparatus, to produce machine- implemented processes.
  • the lab clearinghouse data store 300 may store patient data 304, lab data 308, physician data 306, payer data 310, provider data 311, and/or analytical engine data 302.
  • Patient data 304 may include various information, such as profile data (e.g., preference data, name, address, contact information, insurance provider, etc.), genomic data (e.g., genomic test results), persistent data (e.g., sex, birthdate, race, date of death, etc.), historical data (e.g., past disease conditions, medical tests and results, surgeries, family medical data, etc.) particular to the patient (e.g., regardless of the medical provider, laboratory, and lab payer).
  • profile data e.g., preference data, name, address, contact information, insurance provider, etc.
  • genomic data e.g., genomic test results
  • persistent data e.g., sex, birthdate, race, date of death, etc.
  • historical data e.g., past disease conditions, medical tests and results, surgeries, family medical data, etc.
  • Lab data 308 may include various information, such as profile data (e.g., preference data, name, address, contact information, etc.), historical data (e.g., prior labs performed, etc.), location data (e.g., region, state, etc.), and pricing data (e.g., current pricing structure, past pricing structure, etc.) particular to a laboratory (e.g., regardless of the medical provider, patient, and lab payer).
  • profile data e.g., preference data, name, address, contact information, etc.
  • historical data e.g., prior labs performed, etc.
  • location data e.g., region, state, etc.
  • pricing data e.g., current pricing structure, past pricing structure, etc.
  • Provider data 311 may include various information, such as profile data (e.g., preference data, name, address, contact information, etc.), historical data (e.g., prior labs requested, etc.), location data (e.g., region, state, etc.), and pricing data (e.g., current pricing structure, past pricing structure, etc.) particular to the medical provider (e.g., regardless of the patient, laboratory, and lab payer).
  • profile data e.g., preference data, name, address, contact information, etc.
  • historical data e.g., prior labs requested, etc.
  • location data e.g., region, state, etc.
  • pricing data e.g., current pricing structure, past pricing structure, etc.
  • this provider data 311 may be retrieved from a wide variety of sources, such as any of the devices that may interact with the lab clearinghouse 120.
  • the lab clearinghouse data store 300 may acquire and store physician data 306, which may be more specific to individual physicians (rather than a group of physicians which may be referred to as a single provider) and may include various information, such as profile data (e.g., preference data, name, address, contact information, etc.), historical data (e.g., prior labs requested, etc.), location data (e.g., region, state, etc.), and pricing data (e.g., current pricing structure, past pricing structure, etc.) particular to the physician (e.g., regardless of the medical provider (e.g., hospital or physician group), patient, laboratory, and lab payer), and payer data 310, which may include various information, such as profile data (e.g., preference data, name, address, contact information, etc.), historical data (e.g., prior payments,
  • profile data e.g., preference data, name,
  • Overlap among the data obtained by the lab clearinghouse data store 300 among the patient data 304, lab data 308, physician data 306, payer data 310, provider data 311, and/or analytical engine data 302 may occur and information from one or more of these databases may be retrieved from the medical provider 110A, lab payer 110B, and laboratory 110C to support the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and lab management circuitry 402.
  • Requests for additional data may be transmitted by the lab clearinghouse device 120 to the appropriate medical provider 110A, lab payer 110B, laboratory 110C, or combinations thereof to obtain additional information needed in analyzing the lab request.
  • the additional data may be stored in the lab clearinghouse data store 300.
  • Lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and lab management circuitry 402 can be configured to analyze multiple sets of requests, indications, lab payments, lab fees, data, other communications discussed herein and combinations thereof, such as any combination of the data in the lab clearinghouse data store 300. In this way, lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and lab management circuitry 402 may execute multiple algorithms, including those discussed below with respect to the lab clearinghouse system 100.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and lab management circuitry 402 may include a context determination circuitry 4l4a-4l4c, an analytical engine 4l6a-4l6c, and communications interface 4l8a-4l8c, all of which may be in communication with the lab clearinghouse data store 300.
  • the context determination circuitry 4l4a-4l4c may be implemented using one or more of the components of apparatus 200.
  • the context determination circuitry 4l4a-4l4c may be implemented using one or more of the processor 210, memory 220, communications circuitry 230, and input/output circuitry 240.
  • the context determination circuitry 4l4a-4l4c may be implemented using one or more of the processor 210 and memory 220.
  • the analytical engine 4l6a-4l6c may be implemented using one or more of the processor 210, memory 220, communications circuitry 230, and input/output circuitry 240.
  • the analytical engine 4l6a-4l6c may be implemented using one or more of the processor 210 and memory 220.
  • the communications interface 4l8a-4l8c maybe implemented using one or more of the processor 210, memory 220, communications circuitry 230, and input/output circuitry 240.
  • the communications interface 4l8a-4l8c may be implemented using one or more of the communications circuitry 230 and input/output circuitry 240.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and lab management circuitry 402 may receive one or more communications (e.g., lab requests, lab payments, lab results indications, revised lab requests, relevant data, etc.) and may generate the appropriate communications (e.g., lab fee indication, lab instructions, lab request denial, suggested revised lab request, warning indication, etc.) in response.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and lab management circuitry 402 may use any of the algorithms or processes disclosed herein for receiving any of the requests, indications, payments, fees, data, etc. discussed herein and generating the appropriate communications and/or data in response.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and/or lab management circuitry 402 may be located in another apparatus 200 or another device, such as another server and/or client devices.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and lab management circuitry 402 can be configured to access data corresponding to multiple medical providers 110A (e.g., physicians), lab payers 110B, laboratories 110C, patients, etc., and generate one or more appropriate requests, indications, lab fees, lab payments, data, and/or other communications in response.
  • medical providers 110A e.g., physicians
  • lab payers 110B e.g., laboratories 110C, patients, etc.
  • lab management circuitry 402 can be configured to access data corresponding to multiple medical providers 110A (e.g., physicians), lab payers 110B, laboratories 110C, patients, etc., and generate one or more appropriate requests, indications, lab fees, lab payments, data, and/or other communications in response.
  • the system may receive a plurality of inputs 4l2a-4l2c, 4l5a-4l5c from the apparatus 200 and process the inputs within the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and/or lab management circuitry 402 to produce an output 420a-420c, which may include appropriate requests, indications, lab fees, lab payments, data, and/or other communications in response.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and/or lab management circuitry 402 may execute context determination using the context determination module 4l4a-4l4c, process the communication and/or data in an analytical engine 4l6a-4l6c, and output the results via a communications interface 4l8a-4l8c. Each of these steps may retrieve data from a variety of sources including the lab clearinghouse data store 300.
  • the context determination circuitry 4l4a-4l4c may make a context determination regarding the communication.
  • a context determination includes such information as a user preference data, when and what user initiated generation of the input (e.g., when and who selected the actuator that initiated the lab request), what type of input was provided (e.g., was a lab request initiated or a revised lab request initiated) and under what circumstances receipt of the input was initiated (e.g., patient data, provider data, etc. related to the input).
  • This information may give context to the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and/or lab management circuitry 402 for subsequent determinations ⁇
  • the context determination circuitry 4l4a-4l4c may inform the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401; and/or lab management circuitry 402 as to the communication content to output with a communication.
  • the lab clearinghouse circuitry 400; fraud, waste, and abuse circuitry 401 ; and/or lab management circuitry 402 may then compute the output using the analytical engine 4l6a-4l6c.
  • the analytical engine 4l6a-4l6c draws the applicable data from the lab clearinghouse data store 300 and then, based on the context determination made by the context determination circuitry 4l4a-4l4c, computes an output, which may vary based on the input.
  • the communications interface 4l8a-4l8c then outputs the output 420a-420c to the apparatus 200 for display on the appropriate device. For instance, the context determination circuitry 4l4a-4l4c may determine that a lab request was received from a medical provider 110A.
  • the analytical engine 4l6a-4l6c may determine an appropriate output 420a-420c, such as whether a lab request denial should be generated and transmitted to the lab request initiator, whether a lab fee indication should be generated and transmitted to a lab payer 110B, whether lab instructions should be generated and transmitted to a laboratory 110C, whether a warning indication should be generated and transmitted to any one of the lab request initiator, medical provider 110A (if not the lab request initiator), lab payer 110B, or laboratory 110C, etc.
  • the analytical engine 4l6a-4l6c may also determine that certain data in the lab clearinghouse data store 300 should be updated to reflect the new information contained in the received input. Similarly, the context determination circuitry 4l4a-4l4c may determine that a revised lab request, lab payment, lab results indication, or the like was received, and may further determine whether any additional contextual information was received, and the analytical engine 4l6a-4l6c may determine the appropriate output based on this information as well as additional information from the lab clearinghouse data store 300, as further described herein.
  • any such computer program instructions and/or other type of code may be loaded onto a computer, processor or other programmable apparatus’ s circuitry to produce a machine, such that the computer, processor other programmable circuitry that execute the code on the machine create the means for implementing various functions, including those described herein.
  • all or some of the information presented by the example devices and systems discussed herein can be based on data that is received, generated and/or maintained by one or more components of a local or networked system and/or apparatus 200.
  • one or more external systems such as a remote cloud computing and/or data storage system may also be leveraged to provide at least some of the functionality discussed herein.
  • embodiments of the present invention may be configured as methods, personal computers, servers, mobile devices, backend network devices, and the like. Accordingly, embodiments may comprise various means including entirely of hardware or any combination of software and hardware. Furthermore, embodiments may take the form of a computer program product on at least one non-transitory computer-readable storage medium having computer-readable program instructions (e.g., computer software) embodied in the storage medium. Any suitable computer-readable storage medium may be utilized including non-transitory hard disks, CD-ROMs, flash memory, optical storage devices, or magnetic storage devices.
  • FIGs. 5a-5c illustrates a flow diagram of an example lab clearinghouse system for centralized management of medical tests, in accordance with some embodiments discussed herein.
  • the operations illustrated in FIGs. 5a-5c may, for example, be performed by, with the assistance of, and/or under the control of an apparatus 200, as described above.
  • performance of the operations may invoke one or more of processor 210, memory 220, input/output circuitry 240, communications circuitry 230, and/or lab clearinghouse circuitry 400 (e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a); fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); and/or lab management circuitry 402 (e.g., context determination circuitry 414c, analytical engine 416c, and/or communications interface 418c).
  • processor 210 e.g., memory 220, input/output circuitry 240, communications circuitry 230, and/or lab clearinghouse circuitry 400
  • FIG. 5a illustrates a flow diagram of exemplary operations of a lab clearinghouse system including lab clearinghouse circuitry in accordance with some embodiments discussed herein.
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for receiving a lab request from a lab request initiator (502).
  • input/output circuitry 240 may receive a lab request from a user while communications circuitry 208 may receive data from another device.
  • the lab request initiator may be a medical provider and may be specific to a single physician, a group of physicians, a hospital, or other collection of medical providers with the credentials to order medical testing of a patient or patient’s specimen.
  • the lab request may request the performance of one or more medical tests and may include various information relative to the medical tests, patient, lab request initiator, laboratory for performing the medical tests, etc.
  • the lab clearinghouse device 120 and lab request initiator may communicate to generate the lab request prior to the lab clearinghouse device 120 receiving the lab request.
  • the lab clearinghouse device 120 may present a series of questions to the lab request initiator. The answers of such questions may form the lab request.
  • the apparatus 200 includes means, such as processor 210, memory 220, lab clearinghouse data store 300, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for translating the lab request to a lab code associated with a lab fee (504).
  • the lab request may be translated to a lab code by comparing the one or more medical tests requested in the lab request to a predetermined set of lab codes associated with the medical tests and correlating the medical tests to one or more lab codes.
  • Each medical test may be associated with an individual or unique lab code or may be grouped together under an individual lab code.
  • the lab codes are generally associated with lab fees and may be associated with a single lab fee or a range of lab fees.
  • Translation of the lab request to the lab code may include calculating the appropriate lab code and lab fee based on the medical tests requested. Translation of the lab request to the lab code may consider any of the various information stored in the lab clearinghouse data store (e.g., patient data, physician data, provider data, laboratory data, payer data, or combinations thereof).
  • the apparatus 200 includes means, such as processor 210, memory 220, lab clearinghouse data store 300, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for causing the lab request to be adjudicated (506).
  • the lab request may be adjudicated in real time. That is, after receipt of the lab request, the lab request may be adjudicated prior to transmitting lab instructions to a laboratory 110C for performance of the medical tests requested in the lab request.
  • the lab clearinghouse device has access to a variety of information that may allow for adjudication of the lab request prior to performance of the medical tests requested in the lab request.
  • Adjudication of the lab request may be performed by the lab clearinghouse device 120 and/or the lab payer 110B.
  • both the lab clearinghouse device 120 and the lab payer 110B may communicate to adjudicate the lab request prior to performance of the medical tests requested in the lab request.
  • adjudication of the lab request may be performed autonomously by the lab clearinghouse device 120.
  • the lab clearinghouse device 120 may analyze patient data, physician data, provider data, laboratory data, payer data, or combinations thereof; and determine a likelihood of payment by at least one lab payer of a plurality of lab payers by comparing the patient data, physician data, provider data, lab data, payer data, or combinations thereof to the lab request.
  • the likelihood of payment by the at least one lab payer of the plurality of lab payers may be based on a pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof.
  • the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on a series of prior payments made by a patient, insurance carrier, or combinations thereof.
  • the pattern of activity may establish a payment history of the insurance carrier over a series of prior payments made by the insurance carrier for the patient or for several patients. Such pattern of activity may be used to determine the likelihood of payment by the insurance carrier for future medical tests.
  • the pattern of activity may establish a payment history of the patient or member over a series of prior payments made by the patient or member, which similarly may be used to determine the likelihood of payment by the patient or member for future medical tests.
  • the series of prior payments may be limited to certain prior medical tests or grouped together by similarity in medical tests to which they relate.
  • the pattern of activity established in the patient data, physician data, provider data, lab data, payer data, or combinations thereof may be based on established procedures associated with a patient, lab payer, or combinations thereof.
  • the pattern of activity may be based on policies of the insurance carrier that may distinguish certain medical tests which the insurance carrier may fully or partially reimburse.
  • the pattern of activity may show how the established procedures are followed.
  • the pattern of activity may be based on prior medical tests, prior payments, established procedures, or combinations thereof.
  • the pattern of activity may show that for the past several years, certain medical tests are fully or partially reimbursed by a lab payer or that certain medical tests are only fully or partially reimbursed by a lab payer when described in a certain fashion in accordance with an established procedure of the lab payer.
  • the pattern of activity may be based on real time interactions with the lab request initiator and the lab clearinghouse device 120.
  • the lab clearinghouse device 120 may communicate with the lab request initiator to generate the lab request.
  • a series of questions may be presented to the lab request initiator from the lab clearinghouse device 120 to generate the lab request.
  • the answers to the series of questions may form the pattern of activity that is then used to determine a likelihood of payment.
  • the lab clearinghouse device 120 may retrieve patient data, physician data, provider data, lab data, payer data, or combinations thereof from one or more external devices operated by one or more of a plurality of laboratories, medical providers, lab payers, or combinations thereof in adjudicating the lab request. To facilitate adjudication of the lab request, the lab clearinghouse device 120 may request and receive additional data needed in adjudicating the lab request. For instance, the lab clearinghouse device 120 may request and retrieve additional patient data (e.g., biographical data, diagnosis, etc.), lab data (e.g., which laboratory is requested), lab payer data (e.g., which insurance carrier(s) are implicated by the lab request), or any other data that may be needed in adjudicating the lab request.
  • patient data e.g., biographical data, diagnosis, etc.
  • lab data e.g., which laboratory is requested
  • lab payer data e.g., which insurance carrier(s) are implicated by the lab request
  • adjudication of the lab request may include translating the lab request to a lab request indication and providing the lab request indication to a lab payer, wherein the lab request indication is configured to allow the lab payer to determine a likelihood of approval of the lab request associated with the lab request indication.
  • the lab request indication may be configured to allow the lab payer to determine a likelihood of approval of the lab request associated with the lab request indication by including relevant information (e.g., patient data, physician data, provider data, laboratory data, payer data, or combinations thereof) in the lab request indication such that the lab payer can determine whether the medical tests requested in the lab request would likely be paid for (or how much of the lab request would likely be paid for) by one or more lab payers.
  • One or more lab payers may be involved (e.g., multiple insurance policies may be triggered by the medical tests, patients may be responsible for part or all of the medical tests, etc.).
  • the lab payers may communicate with the lab clearinghouse device to adjudicate the lab requests.
  • the apparatus 200 includes means, such as processor 210, memory 220, lab clearinghouse data store 300, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for approving or denying the lab request based on adjudication of the lab request (508).
  • approving the lab request based on adjudication of the lab request may include generating and transmitting a lab fee indication to one lab payer of the plurality of lab payers, generating lab instructions associated with the lab request, 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. As shown in FIG.
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for transmitting a lab fee indication to a lab payer (510).
  • processor 210 memory 220
  • input/output circuitry 240 communications circuitry 230
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c
  • a lab payer 510
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for receiving a lab payment indication from the lab payer (512).
  • means such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for receiving a lab payment indication from the lab payer (512).
  • One or more lab payers 110B may receive the lab fee indication and a lab payment indication indicating that payment will be provided may be transmitted from one or more lab payers 110B. Lab payment may be transmitted at that time or at a later date.
  • one or more insurance carriers may transmit a payment for the lab request and in some embodiments, a patient may be responsible for payment of part or all of the medical tests requested in the lab request. The patient may transmit a lab payment for the medical tests requested in the lab request.
  • the lab fee indication may be transmitted to a lab payer (e.g., an insurance carrier, patient, member, etc. via a client device or an intermediary device, such as a provider 110A) and lab payment may be transmitted from a lab payer (e.g., an insurance carrier, patient, member, etc. via a client device or an intermediary device, such as a provider 110A).
  • a lab fee indication may be transmitted to a provider 110A which then provides the lab fee indication to the patient or member for payment.
  • the lab fee indication may be transmitted to multiple lab payers and lab payment may be received from multiple lab payers.
  • the apparatus 200 includes means, such as processor 210, memory 220, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for generating lab instructions for performance of one or more medical tests (514).
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for transmitting lab instructions to a laboratory (514).
  • the lab clearinghouse device 120 may generate lab instructions and transmit such instructions to one or more laboratories 110C.
  • the lab instructions may specify certain medical tests to be performed, time and date of performance, conditions needed for performance of the medical tests (e.g., to avoid inaccurate testing, mishandling of specimens, or inconsistency across laboratories), and any other information that may enable the receiving laboratory 110C in performing the medical tests requested in the associated lab request.
  • the lab instructions may be transmitted to a single laboratory 110C for performance of the one or more medical tests requested in the lab request. In some embodiments, the lab instructions may be transmitted to more than one laboratory 110C for performance of one or more medical tests requested in the lab request.
  • the laboratory 110C to which lab instructions are transmitted may be determined by the lab request initiator. Each laboratory 110C may be instructed to perform a certain medical test or may be instructed that certain medical tests are needed and request confirmation of whether the medical tests can be performed.
  • the lab clearinghouse device 120 may communicate with the laboratories 110C such that the medical tests requested in the lab request are performed.
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for receiving a lab results indication associated with the lab request from the laboratory (516).
  • the laboratory 110C may generate and transmit a lab results indication to the lab clearinghouse device 120.
  • the lab results indication may indicate that lab results have been obtained and may list the lab results.
  • the lab clearinghouse device 120 may then transmit the lab results indication with the lab results to one or more of the medical provider 110A and lab payer 110B associated with the lab request.
  • the lab clearinghouse device 120 may transmit the lab results indication with the lab results to the patient (via a client device) associated with the lab request using means such as input/output circuitry 240, communications circuitry 230.
  • the lab clearinghouse device 120 may store the lab results indication and the lab results in apparatus 200, such as in the lab clearinghouse data store 300.
  • the laboratory 110C beneficially may not need to generate and submit insurance claims relating to the medical tests to a lab payer 110B.
  • the laboratory 110C may communicate solely with the lab clearinghouse device 120 to transmit lab results indications and lab results and receive payment for performance of the medical tests.
  • the laboratory 110C is thereby more likely to receive payment (as payment has already been received by the lab clearinghouse device 120 prior to instructing performance of the medical tests, or payment has already been approved by the lab payer, even if payment has not yet been transmitted) and as a result, utilization of the lab clearinghouse system can eliminate the administrative and overhead costs associated with generating and submitting claims and following-up to negotiate the terms of payment for performance of the medical tests.
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for generating and transmitting a lab request denial to the lab request initiator to revise the lab request or may deny the lab request without suggested revisions.
  • the method (500) may include transmitting a lab request denial to the lab request initiator (518).
  • the lab request denial may indicate that the lab request needs to be revised and may include a suggested revised lab request.
  • the suggested revised lab request may be generated by the lab clearinghouse device 120 to overcome problems that were found with the original lab request. That is, the suggested revised lab request may include one or more medical tests to replace one or more medical tests requested in the original lab request. After adjudicating the lab request, the lab clearinghouse device 120 may determine that other medical tests would have a higher likelihood of payment.
  • the lab clearinghouse device has access to a variety of information (e.g., patient data, physician data, provider data, laboratory data, payer data, or combinations thereof) that may allow for providing suggested revised lab requests.
  • the suggested revised lab request may include various information such as revised laboratories to perform the medical tests, revised deadlines, revised patient data, etc.
  • the lab clearinghouse device 120 may determine that the medical tests may not be fully or partially paid for by the insurance carrier and suggest one or more different medical tests in the suggested revised lab requests that would likely be paid for by the insurance carrier.
  • the apparatus 200 may include means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c), or the like, for receiving a revised lab request from the lab request initiator.
  • the lab request initiator e.g., medical provider 110A
  • the revised lab request may include one or more medical tests to replace one or more medical tests requested in the original lab request.
  • the revised lab request may include various information such as revised laboratories to perform the medical tests, revised deadlines, revised patient data, etc. that may enable the lab request to be paid by the lab payer prior to performance of any medical tests stemming from the lab request.
  • Receipt of the revised lab request may cause the method to return to operation 502, described above including receiving a lab request from the lab request initiator and then translating the revised lab request to a lab code and lab fee.
  • the method (500) may then proceed through causing the revised lab request to be adjudicated and approving or denying the revised lab request. It will be appreciated that these operations are similar to the operations of receiving a lab request from the lab request initiator (502), translating the lab request to a lab code and lab fee (504), causing the lab request to be adjudicated (506), and approving or denying the lab request (508) as discussed above.
  • the method 500 may include receiving the original lab request after transmitting the lab request denial.
  • the original lab request may be resubmitted overriding the lab request denial. For instance, a provider, e.g., a physician, may determine that the original lab request should not have been denied and may resubmit the lab request without adjusting the content of the lab request.
  • the method 500 may proceed directly to approving the original lab request or not (508), as discussed above.
  • FIG. 5b illustrates a flow diagram of exemplary operations of a lab clearinghouse system including fraud, waste, and abuse circuitry in accordance with some embodiments discussed herein.
  • FIG. 5b illustrates a flow diagram of an example lab clearinghouse system for reducing fraud, waste, and abuse in accordance with some embodiments discussed herein.
  • the operations illustrated in FIG. 5b may, for example, be performed by, with the assistance of, and/or under the control of an apparatus 200, as described above.
  • performance of the operations may invoke one or more of processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; and/or fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b).
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 418b), or the like, for receiving a lab request from a lab request initiator (522).
  • input/output circuitry 240 may receive a lab request from a user, whereas in another such embodiment, communications circuitry 208 may receive data from another device.
  • the lab request initiator may be a medical provider and may be specific to a single physician, a group of physicians, a hospital, or other collection of medical providers with the credentials to order medical testing of a patient or patient’s specimen.
  • the lab request may request the performance of one or more medical tests and may include various information relevant to the medical tests, patient, lab request initiator, laboratory for performing the medical tests, etc.
  • the apparatus 200 includes means, such as processor 210; memory 220; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for determining whether fraud, waste, and/or abuse are likely with regards to the lab request (524).
  • means such as processor 210; memory 220; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for determining whether fraud, waste, and/or abuse are likely with regards to the lab request (524).
  • the determination of whether fraud, waste, and/or abuse are likely with regards to the lab request may be performed in real time. That is, after receipt of the lab request, the lab clearinghouse device 120 may determine whether fraud, waste, and/or abuse are likely with regards to the lab request prior to transmitting lab instructions to a laboratory 110C for performance of the medical tests requested in the lab request.
  • the lab clearinghouse device has access to a variety of information that may allow for determining whether fraud, waste, and/or abuse are likely with regards to the lab request prior to execution or performance of the medical tests requested in the lab request.
  • the lab clearinghouse device 120 may request additional information from various entities, such as the patient, laboratory 110C, lab payer 110B, medical provider 110A, etc.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for transmitting a request for additional data (546) to any of the entities discussed herein (e.g., patient, laboratory 110C, lab payer 110B, medical provider 110A, etc.).
  • the request for additional data may specify the information requested and such information may enable the apparatus 200 to determine whether fraud, waste, and/or abuse are likely with regards to the lab request.
  • both the lab clearinghouse device 120 and the lab payer 110B may communicate to determine whether fraud, waste, and/or abuse are likely with regards to the lab request prior to execution or performance of the medical tests requested in the lab request.
  • the lab clearinghouse device 120 may determine whether fraud, waste, and/or abuse are likely by determining whether the lab request aligns with pre- established data associated with the lab request. For instance, in some embodiments, the lab clearinghouse device 120 may determine, based on an analysis of the lab request; the medical tests ordered in the lab request; the patient, physician, provider, lab payer, or laboratory data associated with the lab request; or combinations thereof, that the performance of the medical tests requested in the lab request may be wasteful. In some embodiments, based on this analysis, the lab clearinghouse device 120 may determine that the ordering of the medical tests requested in the lab request may be an abuse of discretion. In some embodiments, based on this analysis, the lab clearinghouse device 120 may determine that the ordering of the medical tests requested in the lab request may be fraudulent. Some example procedures by which the lab clearinghouse device 120 may make these determinations are outlined below.
  • the pre-established data may include patient data, physician data, provider data, lab data, payer data, or a combination thereof.
  • the lab clearinghouse device has access to historical data in each of these categories and can use such data for learning and predictive analytics (e.g., prevalence of diseases such as based on specific genome markers) to determine whether fraud, waste, or abuse are likely or not (in which case the lab request should be modified or discarded and a warning indication may be generated and transmitted).
  • the pre-established data may include patient data (e.g., a radius of location where the patient lives, whether the patient is male or female, the age of the patient, prior diagnosis, etc.) and may be used to evaluate whether fraud, waste, or abuse are likely.
  • the pre-established data indicates that the patient lives in the southeast and the lab request is from a lab request initiator located in the northwest, then a comparison of the pre-established data and the lab request would indicate that the two do not align and fraud, waste, or abuse may be likely (a warning indication may be generated and transmitted to the patient (via a client device)).
  • the pre-established data indicates that the patient is a male and the lab request is for medical tests typically requested for females, then a comparison of the pre-established data and the lab request would indicate that the two do not align and fraud, waste, or abuse may be likely (a warning indication may be generated and transmitted to the patient (via a client device)).
  • the pre-established data indicates that the patient is young and the lab request is for medical tests typically requested for older patients, then a comparison of the pre-established data and the lab request would indicate that the two do not align and fraud, waste, or abuse may be likely (a warning indication may be generated and transmitted to the patient (via a client device)).
  • the pre-established data indicates that the patient was previously diagnosed with a certain condition and the lab request is for medical tests that would not be suitable for a patient with such condition, then a comparison of the pre-established data and the lab request would indicate that the two do not align and fraud, waste, or abuse may be likely (a warning indication may be generated and transmitted to the patient (via a client device)).
  • the pre-established data indicates that certain medical tests were previously performed on the patient or patient’s specimen and the lab request is for those same medical tests, then a comparison of the pre-established data and the lab request would indicate that the two do not align and fraud, waste, or abuse may be likely (a warning indication may be generated and transmitted to the patient and/or lab request initiator (via a client device)).
  • the pre-established data may form a pre-established practice and may be used to evaluate whether fraud, waste, or abuse are likely with regards to a lab request.
  • the pre- established practice may be associated with a different patient, provider (e.g., physician), laboratory, lab payer, etc. than that of the lab request being evaluated. For instance, a plurality of providers may request certain medical tests with certain patients/diagnoses. The occurrence of these requests may form a pre-established practice that can then be used to evaluate whether the present lab request aligns with the pre-established practice.
  • the present lab request does not include the medical tests typically ordered for similar patients/diagnoses, includes more medical tests than typically ordered, or includes more expensive medical tests than typically ordered, then fraud, waste, or abuse may be likely (a warning indication may be generated and transmitted to the patient (via a client device)).
  • the lab clearinghouse device 120 may determine that fraud, waste, or abuse are likely. For instance, the patient data or pre-established practices across similar patients may indicate that the presently requested medical tests may be wasteful (e.g., redundant, would not actually provide the desired information, or would provide more information than needed), an abuse of power (e.g., clearly not needed in view of prior medical tests), or fraudulent (e.g., intentionally redundant or not needed, such as if the patient is deceased, lives in another part of the country, or the age/sex of the patient indicates the medical test is fraudulent).
  • the patient data or pre-established practices across similar patients may indicate that the presently requested medical tests may be wasteful (e.g., redundant, would not actually provide the desired information, or would provide more information than needed), an abuse of power (e.g., clearly not needed in view of prior medical tests), or fraudulent (e.g., intentionally redundant or not needed, such as if the patient is deceased, lives in another part of the country, or the age/sex of the patient indicates the medical test is fraudulent).
  • the provider data or pre-established practice across providers may indicate that the presently requested medical tests requested by a different provider may be wasteful (e.g., redundant), an abuse of power, or fraudulent (e.g., intentionally redundant or not needed).
  • the lab payer data or pre-established practice across lab payers may indicate that the presently requested medical tests may be wasteful (e.g., provide more information than needed and is not fully covered by the lab payer), an abuse of power (e.g., provide more information than needed but may be fully covered by the lab payer), or fraudulent (e.g., provide more information than needed but is known to be fully covered by the lab payer). Combinations of this data may be used to identify potential fraud, waste, and abuse.
  • the lab clearinghouse device 120 may generate a warning indication 548 and transmit the warning indication (550) to an appropriate party (e.g., a patient, provider, laboratory, lab payer, etc.).
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 418b); or the like, for generating a warning indication 548 and transmitting a warning indication 550.
  • the warning indication may include a suggested revised lab request.
  • the lab clearinghouse device 120 may determine that the performance of one or more medical tests requested in the lab request may be wasteful, then the lab clearinghouse device 120 may generate and transmit a warning indication to the lab request initiator indicating the defect in the lab request.
  • the warning indication may be transmitted to a patient indicating the defects in the lab request and requesting confirmation that the lab request should be approved.
  • the warning indication may be sent to any of the patient (via a client device), provider 110A, lab payer 110B, laboratory 110C, or combinations thereof.
  • the lab clearinghouse device 120 may determine that the ordering of the lab request may be an abuse of power, then the lab clearinghouse device 120 may generate and transmit a warning indication to the patient indicating the defect in the lab request.
  • the lab clearinghouse device 120 may determine that the ordering of the lab request may be fraudulent, then the lab clearinghouse device 120 may generate and transmit a warning indication to the patient indicating the defect in the lab request.
  • method (520) may include approving or denying the lab request (528).
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b); or the like, for approving or denying the lab request (528).
  • a lab fee indication may be transmitted to one lab payer of the plurality of lab payers, lab instructions associated with the lab request may be generated, and lab instructions associated with the lab request may be transmitted to one laboratory of the plurality of medical laboratories for performance of the lab instructions.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b); or the like, for transmitting a lab fee indication to a lab payer (530).
  • One or more lab payers 110B may receive the lab fee indication and a lab payment indication indicating that payment will be provided may be transmitted from one or more lab payers 110B. Lab payment may be transmitted at that time or at a later date.
  • one or more insurance carriers may transmit a payment for the lab request and in some embodiments, a patient may be responsible for payment of part or all of the medical tests requested in the lab request.
  • the patient may transmit a lab payment for the medical tests requested in the lab request.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for receiving a lab payment from the lab payer (532).
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for generating lab instructions to a laboratory (534) and for transmitting lab instructions to a laboratory (535).
  • means such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for generating lab instructions to a laboratory (534) and for transmitting lab instructions to a laboratory (535).
  • the processor 210; memory 220; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 418b); or the like, may generate lab instructions and the input/output circuitry 240 and/or communications circuitry 230 may transmit lab instructions to a laboratory.
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 418b
  • the processor 210; memory 220; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 may generate lab instructions and the input/output circuitry 240 and/or communications circuitry 230 may transmit lab instructions to a laboratory.
  • the lab clearinghouse device 120 may generate lab instructions and transmit such instructions to one or more laboratories 110C.
  • the lab instructions may specify certain medical tests to be performed, time and date of performance, conditions needed for performance of the medical tests (e.g., to avoid inaccurate testing, mishandling of specimens, or inconsistency across laboratories), and any other information that may enable the receiving laboratory 110C to perform the medical tests requested in the associated lab request.
  • the lab instructions may be transmitted to a single laboratory 110C for performance of the one or more medical tests requested in the lab request. In some embodiments, the lab instructions may be transmitted to more than one laboratory 110C for performance of one or more medical tests requested in the lab request.
  • the laboratory 110C to which lab instructions are transmitted may be determined by the lab request initiator. Each laboratory 110C may be instructed to perform a certain medical test or may be instructed that certain medical tests are needed and request confirmation of whether the medical tests can be performed.
  • the lab clearinghouse device 120 may communicate with the laboratories 110C such that the medical tests requested in the lab request are performed.
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for receiving a lab results indication (536).
  • the laboratory 110C may generate and transmit a lab results indication to the lab clearinghouse device 120.
  • the lab results indication may indicate that lab results have been obtained and may list the lab results.
  • the lab clearinghouse device 120 may then transmit the lab results indication with the lab results to one or more of the medical provider 110A and lab payer 110B associated with the lab request.
  • the lab clearinghouse device 120 may transmit the lab results indication with the lab results to the patient (via a client device) associated with the lab request using means such as input/output circuitry 240 and/or communications circuitry 230.
  • the lab clearinghouse device 120 may store the lab results indication and the lab results in apparatus 200, such as in the lab clearinghouse data store 300.
  • the laboratory 110C may communicate solely with the lab clearinghouse device 120 to transmit lab results indications and lab results and receive payment for performance of the medical tests.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for transmitting at least part of the lab payment (538).
  • the laboratory 110C is more likely to receive payment (as payment has already been received by the lab clearinghouse device 120 prior to instructing performance of the medical tests, or payment has already been approved by the lab payer, even if payment has not yet been transmitted) and as a result, utilization of the lab clearinghouse system can eliminate the administrative and efficiency costs associated with following-up on payment for performance of the medical tests.
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b); or the like, for transmitting lab results (540).
  • Lab results may be transmitted to one or more of the lab payer 110B, provider 110A, and/or patient (via a client device).
  • a lab request denial may be transmitted to the lab request initiator.
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 418b); or the like, for transmitting a lab request denial to the lab request initiator (542).
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); or the like, for generating a lab request denial.
  • the lab request denial may indicate that the lab request needs to be revised and may include a suggested revised lab request.
  • the lab request denial may deny the lab request without suggested revisions.
  • the suggested revised lab request may be generated by the lab clearinghouse device 120 to overcome problems that were found with the original lab request. That is, the suggested revised lab request may include one or more medical tests to replace one or more medical tests requested in the original lab request.
  • the lab clearinghouse device 120 may determine that other medical tests would not be fraudulent, wasteful, or an abuse of discretion.
  • the lab clearinghouse device has access to a variety of information (e.g., patient data, physician data, provider data, laboratory data, payer data, or combinations thereof) that may allow for providing suggested revised lab requests.
  • the suggested revised lab request may include various information such as revised medical tests, revised patient data, etc.
  • the lab request initiator e.g., medical provider 110A
  • the lab request initiator may generate and transmit the revised lab request to the lab clearinghouse device 120.
  • the method may return to operation 522 where the revised lab request is received from the lab request initiator and evaluated for fraud, waste, and abuse. It will be appreciated that these operations are similar to the operations of receiving the lab request (522); determining whether fraud, waste, and abuse are likely (524); and approving or denying the lab request (528) as discussed above.
  • the revised lab request may include one or more medical tests to replace one or more medical tests requested in the original lab request.
  • the revised lab request may include various information such as revised laboratories to perform the medical tests, revised medical tests, revised patient data, etc.
  • the method (520) may include receiving the original lab request after transmitting the lab request denial.
  • the original lab request may be resubmitted overriding the lab request denial. For instance, a provider, e.g., a physician, may determine that the original lab request should not have been denied and may resubmit the lab request without adjusting the content of the lab request.
  • the method (520) may proceed directly to approving the original lab request (528) or not as discussed above.
  • FIG. 5c illustrates a flow diagram of exemplary operations of a lab clearinghouse system including lab management circuitry in accordance with some embodiments discussed herein.
  • FIG. 5c illustrates a flowchart containing a series of operations for approving medical tests across a plurality of medical laboratories, medical providers, and lab payers.
  • the operations illustrated in FIG. 5c may, for example, be performed by, with the assistance of, and/or under the control of a lab clearinghouse device 120, as described above.
  • performance of the operations may invoke one or more of processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c), and/or lab clearinghouse data store 300.
  • processor 210 memory 220
  • input/output circuitry 240 communications circuitry 230
  • lab management circuitry 402 e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c
  • lab clearinghouse data store 300 e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c
  • the apparatus 200 includes means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c), or the like, for receiving a lab request from a lab request initiator (552).
  • input/output circuitry 240 may receive a lab request from a user, whereas in another such embodiment, communications circuitry 208 may receive data from another device.
  • the lab request initiator may be a medical provider and may be specific to a single physician, a group of physicians, a hospital, or other collection of medical providers with the credentials to order medical testing of a patient or patient’s specimen.
  • the lab request may request the performance of one or more medical tests and may include various information relevant to the medical tests, patient, lab request initiator, laboratory for performing the medical tests, etc.
  • the apparatus 200 includes means, such as processor 210; memory 220; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like, for evaluating the lab request (554).
  • means such as processor 210; memory 220; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like, for evaluating the lab request (554).
  • the evaluation of the lab request may be performed in real time. That is, after receipt of the lab request, the lab clearinghouse device 120 may evaluate the lab request prior to transmitting lab instructions to a laboratory 110C for performance of the medical tests requested in the lab request.
  • the lab clearinghouse device has access to a variety of information that may allow for evaluating the lab request prior to execution or performance of the medical tests requested in the lab request.
  • the lab clearinghouse device 120 may request additional information from various entities, such as the patient, laboratory 110C, lab payer 110B, medical provider 110A, etc.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like, for retrieving additional data (576) from any of the entities discussed herein (e.g., patient, laboratory 110C, lab payer 110B, medical provider 110A, etc.).
  • the request for additional data may specify the information requested and such information may enable the apparatus 200 to evaluate the lab request.
  • both the lab clearinghouse device 120 and the lab payer 110B may communicate to evaluate the lab request prior to execution or performance of the medical tests requested in the lab request.
  • the lab clearinghouse device 120 may evaluate the appropriateness of the lab request.
  • the appropriateness of the lab request may be determined based on a variety of data, such as patient data, physician data, provider data, lab payer data, laboratory data, or a combination thereof across a plurality of patients, providers, lab payers, and laboratories.
  • Evaluating the appropriateness of the lab request may entail evaluating the completeness of the lab request (e.g., is information missing in the lab request), errors in the lab request (e.g., is any of the information in the lab request incorrect), cost of the lab request (e.g., is there another medical test that would be less costly than that requested in the lab request and still provide the necessary results), quality of the laboratory (e.g., is there a laboratory with a higher degree of quality than the laboratory requested in the lab request or is there a laboratory with a high degree of quality that should be requested in the lab request), insurance coverage (e.g., is there a medical test or laboratory that would be covered by the patient’s insurance and still provide the necessary results), timeliness (e.g., is there a medical test or laboratory that would be more timely, such as more timely than that requested in the lab request, and still provide the necessary results), location (e.g., is there a laboratory that is physically closer to the patient that should be requested in the lab request or is there a medical
  • the evaluation of the appropriateness of the lab request may include consideration of patient data, physician data, provider data, lab data, payer data, or a combination thereof.
  • the lab clearinghouse device has access to historical data in each of these categories and can use such data for learning and predictive analytics to determine the appropriateness of the lab request (e.g., learning and predictive analytics may help identify another medical test that would provide more useful results than that requested in the lab request, such as based on the diagnosis of the patient and medical history of the patient compared to other similarly diagnosed patients, or determine that there is an error in the lab request).
  • the lab clearinghouse device may have access to information specifically concerning patients across a variety of laboratories, providers, and lab payers and can thereby identify errors in the medical tests requested for the patient (e.g., incorrect patient information).
  • the lab clearinghouse device may have access to laboratory data and lab payer data and can thereby determine whether the lab request is complete for the medical tests to be performed by the laboratory and for the lab payer to pay for performance of the medical tests.
  • the cost of medical test varies. Based on historical data, the lab clearinghouse device may determine that a full panel of tests is not needed to provide the desired results and a single test or less than the full panel of tests may be performed and still provide the desired results. Such single test or less than the full panel of tests may be more appropriate for the lab request.
  • the cost of medical tests also varies across laboratories. The lab clearinghouse device may determine that a certain laboratory may provide the desired results at a lower cost than another laboratory and thus would be more appropriate for the lab request.
  • the quality of medical tests may vary across laboratories. Particularly with genomic testing, the quality of medical tests may vary significantly across different laboratories.
  • the lab clearinghouse device may identify laboratories that would provide higher quality results and either modify the lab clearinghouse device to include such laboratory or suggest such laboratory to the lab request initiator.
  • the lab clearinghouse device has access to lab payer data and patient data and can thus direct lab instructions to laboratories that would be covered by the patient’s insurance policy or revise lab requests to include medical tests that would be covered by the patient’ s insurance policy while still providing the desired results.
  • the lab clearinghouse device has access to historical laboratory data across a plurality of laboratories and can thus determine which laboratories are timelier with regards to the performance of certain medical tests.
  • the lab clearinghouse device can thereby direct lab instructions to laboratories that would be timelier or revise lab requests to include laboratories that would be timelier.
  • the lab clearinghouse can also determine is certain medical tests would be timelier than others while still providing the desired results.
  • the lab clearinghouse device can thereby modify or suggest medical tests that would be timelier.
  • the lab clearinghouse device has access to laboratory data across a plurality of laboratories and thus identify laboratories that are physically closer to the patient and/or lab request initiator while still providing the desired results.
  • the lab clearinghouse device can thereby direct lab instructions to laboratories that would be closer or revise lab requests to include laboratories that would be closer to the patient and/or lab request initiator.
  • the lab clearinghouse device can negotiate with laboratories in the performance of medical tests to adjust rates for medical tests and may take on risk of payment by lab payers based on historical data.
  • the lab clearinghouse device may take these adjusted rates and risk into consideration in determining the most appropriate laboratory for performance of the lab request.
  • the evaluation of the appropriateness of the lab request may include the consideration of a plurality of these factors. For instance, the lab clearinghouse device may determine that a specific laboratory has a higher degree of quality, is cheaper, and timelier than another laboratory and would thus be considered more appropriate. The lab clearinghouse device may determine that a specific laboratory is in-network for the patient’s insurance policy and physically closer to the patient and/or provider than other laboratories. The specific laboratory would be deemed more appropriate than other laboratories. The lab clearinghouse device may determine that a specific medical test is more medically suitable for obtaining the desired results and can be performed at a laboratory physically closer to the patient and/or provider than that specified in the lab request. The specific medical test would be deemed more appropriate than the medical test specified in the lab request.
  • the lab clearinghouse device may determine that based on the diagnosis of the patient, a different medical test may be more medically suitable than the medical tests requested in the lab request and may be more likely to be covered by the patient’ s insurance carrier and/or the patient. The specific medical test would be deemed more appropriate than the medical test specified in the lab request.
  • the lab clearinghouse device may modify the lab request to include such medical test and proceed with approving the lab request.
  • the lab clearinghouse device may deny the lab request as will be described later.
  • Whether the lab clearinghouse device modifies the lab request and proceeds with approving the lab request or denies the lab request may be based on the change that would be needed to include the more appropriate medical test or laboratory. For instance, if the change would entail adding a specific laboratory when a laboratory was not listed in the original lab request, then the lab clearinghouse device may modify the lab request to include the specific laboratory and proceed with approving the lab request. If the change would entail replacing a specified medical test with another medical test, then the lab clearinghouse device may deny the lab request and may generate and transmit a suggested revised lab request with the new medical test for consideration by the lab request initiator. If the change would entail replacing a specified laboratory with another laboratory, then the lab clearinghouse device may deny the lab request and may generate and transmit a suggested revised lab request with the new laboratory for consideration by the lab request initiator.
  • method (560) may include approving or denying the lab request (556).
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for approving or denying the lab request (556).
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for approving or denying the lab request (556).
  • lab management circuitry 402 e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c
  • a lab fee indication may be transmitted to one lab payer of the plurality of lab payers, lab instructions associated with the lab request may be generated, and lab instructions associated with the lab request may be transmitted to one laboratory of the plurality of medical laboratories for performance of the lab instructions.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for transmitting a lab fee indication to a lab payer (562).
  • One or more lab payers 110B may receive the lab fee indication and a lab payment indication indicating that payment will be provided may be transmitted from one or more lab payers 110B. Lab payment may be transmitted at that time or at a later date.
  • one or more insurance carriers may transmit a payment for the lab request and in some embodiments, a patient may be responsible for payment of part or all of the medical tests requested in the lab request.
  • the patient may transmit a lab payment for the medical tests requested in the lab request.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for receiving a lab payment from the lab payer (564).
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for generating lab instructions to a laboratory (558) and for transmitting lab instructions to a laboratory (570).
  • means such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for generating lab instructions to a laboratory (558) and for transmitting lab instructions to a laboratory (570).
  • the processor 210; memory 220; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, may generate lab instructions and the input/output circuitry 240 and/or communications circuitry 230 may transmit lab instructions to a laboratory.
  • lab management circuitry 402 e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c
  • the processor 210; memory 220; lab clearinghouse data store 300; lab management circuitry 402 e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c
  • the processor 210 may generate lab instructions and the input/output circuitry 240 and/or communications circuitry 230 may transmit lab instructions to a laboratory.
  • the lab clearinghouse device may include such medical test or laboratory in the lab instructions. That is, the lab clearinghouse may generate lab instructions based on the more appropriate medical test(s) and/or laboratory and transmit such lab instructions to the laboratory.
  • operation 562 transmitting lab fee indication and operation 564 receiving the lab payment may occur prior to operation 558 generating lab instructions such that operation 564 may proceed to operation 558.
  • the lab clearinghouse device 120 may generate lab instructions and transmit such instructions to one or more laboratories 110C.
  • the lab instructions may specify certain medical tests to be performed, time and date of performance, conditions needed for performance of the medical tests (e.g., to avoid inaccurate testing, mishandling of specimens, or inconsistency across laboratories), and any other information that may enable the receiving laboratory 110C to perform the medical tests requested in the associated lab request.
  • the lab instructions may be transmitted to a single laboratory 110C for performance of the one or more medical tests requested in the lab request. In some embodiments, the lab instructions may be transmitted to more than one laboratory 110C for performance of one or more medical tests requested in the lab request.
  • the laboratory 110C to which lab instructions are transmitted may be determined by the lab request initiator. Each laboratory 110C may be instructed to perform a certain medical test or may be instructed that certain medical tests are needed and request confirmation of whether the medical tests can be performed.
  • the lab clearinghouse device 120 may communicate with the laboratories 110C such that the medical tests requested in the lab request are performed.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for receiving a lab results indication (572).
  • the laboratory 110C may generate and transmit a lab results indication to the lab clearinghouse device 120.
  • the lab results indication may indicate that lab results have been obtained and may list the lab results.
  • the lab clearinghouse device 120 may then transmit the lab results indication with the lab results to one or more of the medical provider 110A and lab payer 110B associated with the lab request.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like, for transmitting lab results (568).
  • the lab clearinghouse device 120 may transmit the lab results indication with the lab results to the patient (via a client device) associated with the lab request using means such as input/output circuitry 240 and/or communications circuitry 230.
  • the lab clearinghouse device 120 may store the lab results indication and the lab results in apparatus 200, such as in the lab clearinghouse data store 300. Lab results may be transmitted to one or more of the lab payer 110B, provider 110A, and/or patient (via a client device).
  • the laboratory 110C may communicate solely with the lab clearinghouse device 120 to transmit lab results indications and lab results and receive payment for performance of the medical tests.
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for transmitting at least part of the lab payment (566).
  • the laboratory 110C is more likely to receive payment (as payment has already been received by the lab clearinghouse device 120 prior to instructing performance of the medical tests, or payment has already been approved by the lab payer, even if payment has not yet been transmitted) and as a result, utilization of the lab clearinghouse system can eliminate the administrative and efficiency costs associated with following-up on payment for performance of the medical tests.
  • a lab request denial may be transmitted to the lab request initiator.
  • the apparatus 200 includes means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like, for transmitting a lab request denial to the lab request initiator (574).
  • the apparatus 200 may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse data store 300; lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like, for generating a lab request denial.
  • the lab request denial may indicate that the lab request needs to be revised and may include a suggested revised lab request.
  • the lab request denial may deny the lab request without suggested revisions.
  • the suggested revised lab request may be generated by the lab clearinghouse device 120 to overcome problems that were found with the original lab request. That is, the suggested revised lab request may include one or more medical tests to replace one or more medical tests requested in the original lab request.
  • the lab clearinghouse device 120 may determine that other medical tests would be more appropriate.
  • the lab clearinghouse device has access to a variety of information (e.g., patient data, physician data, provider data, laboratory data, payer data, or combinations thereof) that may allow for providing suggested revised lab requests.
  • the suggested revised lab request may include various information such as revised medical tests, revised patient data, etc.
  • the lab request initiator e.g., medical provider 110A
  • the lab request initiator may generate and transmit the revised lab request to the lab clearinghouse device 120.
  • the method may return to operation 552 where the revised lab request is received from the lab request initiator and then evaluated. It will be appreciated that these operations are similar to the operations of receiving the lab request (552); evaluating the lab request (554); and approving or denying the lab request (556) as discussed above.
  • the revised lab request may include one or more medical tests to replace one or more medical tests requested in the original lab request.
  • the revised lab request may include various information such as revised laboratories to perform the medical tests, revised medical tests, revised patient data, etc.
  • the method (560) may include receiving the original lab request after transmitting the lab request denial.
  • the original lab request instead of receiving a revised lab request, the original lab request may be resubmitted overriding the lab request denial. For instance, a provider, e.g., a physician, may determine that the original lab request should not have been denied and may resubmit the lab request without adjusting the content of the lab request.
  • the method (560) may proceed directly to approving the original lab request (556) or not as discussed above.
  • FIG. 6 illustrates a flow diagram of exemplary operations of an example medical provider in accordance with some embodiments discussed herein.
  • the operations illustrated in FIG. 6 may, for example, be performed by, with the assistance of, and/or under the control of an apparatus 200, as described above.
  • performance of the operations may invoke one or more of processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse circuitry 400 (e.g., context determination circuitry 414a, analytical engine 4l6a, and/or communications interface 4l8a); fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 4l8b); lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like.
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 414a, analytical engine 4l6a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 4l8b
  • lab management circuitry 402 e.g., context determination circuitry 4
  • the medical provider 110A may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse circuitry 400 (e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a); fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 416c, and/or communications interface 418c); or the like for generating a lab request (602), transmitting a lab request to the lab clearinghouse device (604), and receiving lab results (606).
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface
  • the input/output circuitry and/or communications circuitry may transmit a lab request (604) and receive lab results (606).
  • the lab results may include all supporting documentation (e.g., genomic file).
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 414b, analytical engine 4
  • the medical provider 110A may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; fraud, waste, and abuse circuitry 400 (e.g., context determination circuitry 4 l4a-c, analytical engine 4l6a-c, and/or communications interface 4l8a-c); or the like for receiving a lab request denial and/or warning indication (610) and generating and transmitting a revised lab request or resubmit the lab request, such that the method (600) returns to operation 602.
  • the medical provider may receive a lab request denial and/or warning indication and generate and transmit a revised lab request or resubmit the lab request.
  • the medical provider 110A may include means, such as processor 210; memory 220; input/output circuitry 240; communications circuitry 230; lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a); fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b); lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c); or the like for communicating with the lab clearinghouse device (608) to generate the lab request (602).
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b
  • the lab clearinghouse device 120 and medical provider 110A may communicate to generate the lab request.
  • the lab clearinghouse device 120 may present a series of questions to the lab request initiator. The answers of such questions may form the lab request.
  • operation 608 may entail back and forth communication between the medical provider 110A and the lab clearinghouse device 120.
  • FIG. 7 illustrates a flow diagram of exemplary operations of an example lab payer in accordance with some embodiments discussed herein.
  • the operations illustrated in FIG. 7 may, for example, be performed by, with the assistance of, and/or under the control of an apparatus 200, as described above.
  • performance of the operations may invoke one or more of processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a), fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b); and/or lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 418c), or the like.
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b
  • lab management circuitry 402 e.g., context determination circuitry 4
  • the lab payer 110B may include means, such as a processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a), fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); and/or lab management circuitry 402 (e.g., context determination circuitry 414c, analytical engine 4l6c, and/or communications interface 4l8c), or the like, for receiving a lab fee indication (702), generating a lab payment (704), and transmitting a lab payment (706).
  • a processor 210 e.g., memory 220, input/output circuitry 240, communications circuitry 230
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a
  • the input/output circuitry 240 and/or communications circuitry 230 may receive a lab fee indication, the processor 210 and/or memory 220 may generate a lab payment, and the input/output circuitry 240 and/or communications circuitry 230 may transmit a lab payment.
  • the lab payer 110B may also include means, such as a processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a), fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 4l4b, analytical engine 4l6b, and/or communications interface 418b); and/or lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c), or the like, for receiving a lab request indication and determining a likelihood of approval of the lab request associated with the lab request indication.
  • a processor 210 e.g., memory 220, input/output circuitry 240, communications circuitry 230
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4
  • the input/output circuitry 240 and/or communications circuitry 230 may receive a lab request indication and the processor 210 and/or memory 220 may determine a likelihood of approval of the lab request associated with the lab request indication. Receiving a lab request indication and determining a likelihood of approval of the lab request associated with the lab request indication may occur prior to receiving a lab fee indication (702).
  • FIG. 8 illustrates a flow diagram of exemplary operations of an example laboratory in accordance with some embodiments discussed herein.
  • the operations illustrated in FIG. 8 may, for example, be performed by, with the assistance of, and/or under the control of an apparatus 200, as described above.
  • performance of the operations may invoke one or more of processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a), fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b); and/or lab management circuitry 402 (e.g., context determination circuitry 4l4c, analytical engine 4l6c, and/or communications interface 4l8c), or the like.
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 4l4a, analytical engine 4l6a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 4l8b
  • lab management circuitry 402 e.g., context determination circuitry
  • the laboratory 110C may include means, such as processor 210, memory 220, input/output circuitry 240, communications circuitry 230, lab clearinghouse circuitry 400 (e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a), fraud, waste, and abuse circuitry 401 (e.g., context determination circuitry 414b, analytical engine 416b, and/or communications interface 418b); and/or lab management circuitry 402 (e.g., context determination circuitry 414c, analytical engine 4l6c, and/or communications interface 418c), or the like, for receiving lab instructions (802), performing the medical tests indicated in the lab instructions (804), generating a lab results indication (806), and transmitting the lab results indication to the lab clearinghouse device (808).
  • lab clearinghouse circuitry 400 e.g., context determination circuitry 414a, analytical engine 416a, and/or communications interface 4l8a
  • fraud, waste, and abuse circuitry 401 e.g., context determination circuit
  • the input/output circuitry 240 and/or communications circuitry 230 may receive lab instructions, the processor 210 and/or memory 220 may perform the medical tests indicated in the lab instructions and/or generate a lab results indication, and the input/output circuitry 240 and/or communications circuitry 230 may transmit the lab results indication.
  • Lab Clearinghouse Device and Pricing Structure Provided herein are systems, methods, devices, and computer program products to manage lab requests and lab payments
  • the lab clearinghouse device is designed to be the intermediary in transmissions between patients, providers (e.g., physicians, hospitals, etc.), lab payers, and laboratories, and as a result, the lab clearinghouse device has access to information, e.g., electronic medical records, from each of these entities.
  • the lab clearinghouse device may adjudicate the lab request in real-time based on information received from the provider, the member (e.g., patient), the lab payer, and any contract with the lab to perform the medical tests ordered in the lab request thereby eliminating the need for laboratories to create insurance claims for payment, or for lab payers to adjudicate such insurance claims.
  • the lab clearinghouse device may generate and transmit a lab fee indication indicating that payment for one or more medical tests is needed, receive a payment indication indicating that payment will be provided, and generate lab instructions for performance of the medical tests.
  • a lab clearinghouse device as described herein, lab payers and laboratories may realize reduced costs and increased efficiency due to the removal of the need to create insurance claims, and lab payers, patients, and medical providers may have access to data (e.g., detailed and complex test results) through the lab clearinghouse device that may otherwise not be readily accessible.
  • the lab clearinghouse device allows for shifting of the price structure away from claims-based payment adjudication that prices large groups of tests under broad claims to a model that prices medical tests based on the individual requirements of the medical tests themselves. Medical tests may be priced based on the underlying data regarding the lab request (e.g., patient, laboratory, etc.) rather than the insurance claim that results from a lab request.
  • lab clearinghouse device As described herein enables medical tests to be priced based on the actual needs of the patient.
  • the lab request can thereby be adjudicated based on the needs of the patient and can be modified through lab request denials and suggested revised lab requests to obtain a lab request that is more likely to be paid while still meeting the needs of the patient. Denial of payment by insurance companies due to ineligible tests, clinical editing, duplicate tests, etc. can be avoided on the front end.
  • the lab clearinghouse device may allow for less strain on the systems of the medical providers, laboratories, and lab payers leading to increased system efficiency. Due to the removal of the need to create and submit claims, this effect is particularly amplified for laboratories and lab payers and may also allow for reduced network traffic and data processing in other entities (e.g., intermediary systems, collection agencies, and the like).
  • medical tests may be priced more specifically (rather than being grouped with lOO’s of other labs and priced with those other labs), thereby reducing costs for the lab payer and the patient (e.g., due to reduced denials).
  • the lab clearinghouse device may also increase provider engagement as the provider communicates with the lab clearinghouse device to determine the lab request (e.g., through the generation and submission of suggested revised lab requests and revised lab requests). Fraud, Waste, and Abuse Reduction
  • the lab clearinghouse device is designed to be the intermediary in transmissions between patients, providers (e.g., physicians, hospitals, etc.), lab payers, and laboratories, and as a result, the lab clearinghouse device has access to information, e.g., electronic medical records, from each of these entities.
  • the lab clearinghouse device may provide real-time decision support integrations with the ordering provider (e.g., individual physician, physician group, hospital, clinic, etc.) workflow and may provide real-time analysis of a lab request based on information received from the provider, member (e.g., patient), lab payer, and laboratory to reduce fraud, waste, and abuse, and contract with the laboratory to perform the medical tests ordered in the lab request.
  • the lab clearinghouse device can be used for learning and predictive analytics (e.g., prevalence of diseases based on specific genome markers) to determine whether fraud, waste, and abuse are likely.
  • the lab clearinghouse device can be used to trim the volume of future lab work increasing the efficiency and effectiveness of the lab clearinghouse system compared to current practices.
  • the lab clearinghouse device can determine whether fraud, waste, or abuse are likely by comparing the lab request to pre-established data concerning laboratories, providers, and lab payers. For instance, redundant or unnecessary labs can be avoided using historical patient data (e.g., by offering the results of a prior medical test instead of ordering a new medical test, warning the lab request initiator that the medical test was previously performed, or enabling the physician to see previously ordered medical tests for a specific patient).
  • the lab clearinghouse system can thereby avoid waste, reducing costs for patients, providers, laboratories, and lab payers.
  • the lab clearinghouse device can establish pre-established practices associated with the lab request based on a series of lab requests specific to a provider of the plurality of medical providers.
  • the series of lab requests may include lab requests associated with a plurality of different patients.
  • the lab clearinghouse device can also avoid fraud (e.g., by matching the ordering physician or patient against a death file) using patient data as pre-established data.
  • lab results may be transmitted to lab payers, medical providers, and patients (via client devices).
  • the lab clearinghouse device may help reduce the effort associated with capturing supplemental data required for HEDIS and STARS and reduce the need to track down lab results from laboratories directly.
  • the lab clearinghouse device may allow for more accurate lab ordering by determining whether fraud, waste, and abuse are likely and modifying the lab request (e.g., using lab request denials and suggested revised lab requests), thereby reducing costs, system strain, and data processing for patients, laboratories (e.g., laboratories are more likely to be reimbursed for performance of the medical tests), lab payers, and medical providers.
  • the lab clearinghouse device may have access to a variety of information concerning patients, laboratories, lab payers, and medical providers; can retrieve information from providers, lab payers, laboratories, and patients (via client devices); and is thereby able to more accurately evaluate and determine whether fraud, waste, and abuse are likely.
  • the lab clearinghouse device may have access to both the lab request, specifying one or more medical tests to be performed, generate lab instructions, and receive and review lab results.
  • the lab clearinghouse device may receive lab results thereby allowing the lab clearinghouse device to evaluate whether fraud, waste, and abuse are likely and use such information for determining whether fraud, waste, and abuse are likely with regards to future lab requests and further tailor the lab requests and lab instructions based on these determinations ⁇
  • the lab clearinghouse device analyzes the lab requests; transmits lab request denials and receives revised lab requests; has access to data concerning patients, laboratories, lab payers, and medical providers and can communicate with each of these parties (via a client device); and generates and transmits the lab instructions
  • the lab clearinghouse device may reduce issues associated with lab payers and laboratories not fully understanding the medical tests requested.
  • the lab clearinghouse device may determine whether fraud, waste, and abuse are likely prior to generation of lab instructions and performance of the medical tests requested in the lab request. This proactive system may reduce fraud, waste, and abuse, thereby reducing costs and increasing efficiency. Through the use of a lab clearinghouse system employing a lab clearinghouse device, all of the prior technical complexity can be avoided by with the single lab clearinghouse device designed to use pre-established data and determine whether fraud, waste, and abuse are likely prior to generation of lab instructions and performance of the lab requests. Lab Utilization and Benefit Management
  • the lab clearinghouse device is designed to be the intermediary in transmissions between patients, providers (e.g., physicians, hospitals, etc.), lab payers, and laboratories and as a result, the lab clearinghouse device has access to information, e.g., electronic medical records, from each of these entities and can provide real-time evaluation of the lab request prior to execution or performance of the requested medical tests.
  • the lab clearinghouse device may consider various information regarding the patient, laboratories, providers, lab payers, etc., and more effectively manage the lab requests - requesting the right lab for the right patient at the right time - and better anticipate payments and take on risk of payment by the lab payer (e.g., the patient, member, and/or insurance carrier).
  • the lab payer e.g., the patient, member, and/or insurance carrier.
  • Machine learning models can be used to automate authorization of lab requests during the evaluation of the appropriateness of the lab request. Medical testing can be steered to more appropriate laboratories by modifying lab requests or denying and suggesting revised lab requests, thereby reducing costs and increasing efficiencies.
  • the lab clearinghouse device has access to the details of the lab request (e.g., the medical tests requested, information regarding the lab request initiator, etc.) as well as historical information concerning the patient, member, lab payer, provider, and laboratories and can thereby evaluate the appropriateness of the lab request based on this information.
  • the lab clearinghouse device may edit the lab request (e.g., through a lab request denial and suggested revised lab request or through a request for additional data) and then generate lab instructions once the appropriateness of the lab request is confirmed.
  • the resulting lab instructions are more tailored to the information desired in the lab request and more tailored to the patient, member, provider, lab payer, and laboratory affected resulting in more useful lab results for patients and providers, reduced costs, reduced denials by lab payers, increased reimbursements to laboratories, and various other benefits.
  • More appropriate medical testing or more appropriate laboratories may be identified and included in the lab instructions.
  • the lab clearinghouse device may allow for less strain on the systems of the medical providers, laboratories, and lab payers (e.g., due to more appropriate medical testing) leading to increased lifetime and efficiency.
  • the lab clearinghouse device may also allow for reduced network traffic and data processing by shifting the evaluation of the lab request to the front end prior to execution or performance of the medical tests.
  • the lab clearinghouse device may also increase provider engagement as the provider communicates with the lab clearinghouse device to determine an appropriate lab request (e.g., through suggested revised lab requests and revised lab requests).
  • These computer program instructions may also be stored in a computer-readable storage device (e.g., memory 220) that can direct a computer or other programmable data processing apparatus to function in a particular manner, such that the instructions stored in the computer-readable storage device produce an article of manufacture including computer-readable instructions for implementing the function discussed herein.
  • the computer program instructions may also be loaded onto a computer or other programmable data processing apparatus to cause a series of operational steps to be performed on the computer or other programmable apparatus to produce a computer-implemented process such that the instructions that execute on the computer or other programmable apparatus provide steps for implementing the functions discussed herein.
  • blocks of the block diagrams and flowchart illustrations support combinations of means for performing the specified functions, combinations of steps for performing the specified functions and program instruction means for performing the specified functions. It will also be understood that each block of the circuit diagrams and process flowcharts, and combinations of blocks in the circuit diagrams and process flowcharts, can be implemented by special purpose hardware-based computer systems that perform the specified functions or steps, or combinations of special purpose hardware and computer instructions.
  • Some embodiments of the present invention also use a second screen, as discussed herein.
  • a first screen may be presented to a first user while a second screen may be presented to a second user of the lab clearinghouse system 100.
  • the format of the display may appear differently to different users of the lab clearinghouse system 100. For instance, users may have particular preference for layouts or text fonts. The particular preferences may be considered when generating the communications and displays.
  • the system may utilize any number of screens necessary for use of the lab clearinghouse system 100 in a meaningful way to each user of the system.

Abstract

L'invention concerne un dispositif de centre d'échange d'information de laboratoire configuré pour assurer la gestion centralisée d'essais médicaux sur l'ensemble d'une pluralité de fournisseurs médicaux, d'une pluralité de financeurs de laboratoire et d'une pluralité de laboratoires. Le dispositif de centre d'échange d'information de laboratoire est configuré pour communiquer avec une pluralité de laboratoires médicaux, de fournisseurs médicaux et de financeurs de laboratoire afin de commander et de gérer un essai médical avec compétence et efficacité.
PCT/US2018/016901 2018-02-05 2018-02-05 Dispositif pour la gestion centralisée d'essais médicaux et procédés d'utilisation de celui-ci WO2019152056A1 (fr)

Applications Claiming Priority (6)

Application Number Priority Date Filing Date Title
US15/888,682 US11282591B2 (en) 2018-02-05 2018-02-05 Device for the centralized management of medical tests and methods for using the same
US15/888,721 US10930391B2 (en) 2018-02-05 2018-02-05 Device for reducing fraud, waste, and abuse in the ordering and performance of medical testing and methods for using the same
US15/888,682 2018-02-05
US15/888,763 2018-02-05
US15/888,721 2018-02-05
US15/888,763 US10978183B2 (en) 2018-02-05 2018-02-05 Device for approving medical tests across a plurality of medical laboratories, medical providers, and lab payers and methods for using the same

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WO2019152056A1 true WO2019152056A1 (fr) 2019-08-08

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Citations (3)

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US20070294103A1 (en) * 2006-06-14 2007-12-20 Cerner Innovation, Inc. Automated laboratory test ordering and result tracking
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US20110202370A1 (en) * 2002-04-19 2011-08-18 Greenway Medical Technologies, Inc. Integrated medical software system with embedded transcription functionality

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US20110202370A1 (en) * 2002-04-19 2011-08-18 Greenway Medical Technologies, Inc. Integrated medical software system with embedded transcription functionality
US20070294103A1 (en) * 2006-06-14 2007-12-20 Cerner Innovation, Inc. Automated laboratory test ordering and result tracking
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