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WO2000066367A1 - Procede, systeme et reseau permettant de coordonner la communication de donnees pour une transaction liee a la sante - Google Patents

Procede, systeme et reseau permettant de coordonner la communication de donnees pour une transaction liee a la sante Download PDF

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Publication number
WO2000066367A1
WO2000066367A1 PCT/US2000/012331 US0012331W WO0066367A1 WO 2000066367 A1 WO2000066367 A1 WO 2000066367A1 US 0012331 W US0012331 W US 0012331W WO 0066367 A1 WO0066367 A1 WO 0066367A1
Authority
WO
WIPO (PCT)
Prior art keywords
health
insured
care provider
data
provider
Prior art date
Application number
PCT/US2000/012331
Other languages
English (en)
Inventor
Robert E. Dorf
Original Assignee
Dorf Robert E
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 Dorf Robert E filed Critical Dorf Robert E
Priority to AU48229/00A priority Critical patent/AU4822900A/en
Publication of WO2000066367A1 publication Critical patent/WO2000066367A1/fr

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Classifications

    • G—PHYSICS
    • G06—COMPUTING OR CALCULATING; 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
    • G06Q99/00—Subject matter not provided for in other groups of this subclass
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H40/00—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices
    • G16H40/20—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H80/00—ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Definitions

  • the present invention relates to the electronic coordination and communication of data in a health network, and between the health network and a banking network, for a health-related transaction.
  • eligible to receive services may not because of time consuming methods of verifying their
  • an insurance provider i.e., insurance company
  • an insured i.e., an insured
  • health care providers e.g., primary care providers (PCP), specialists, laboratories, pharmacies, hospitals, etc.
  • financial service providers e.g., banks, debit-credit
  • transaction may be communicated between and among the members using a variety of paper
  • While the various computer systems may communicate with each other at some level, complete and current data for a health-related transaction is not electronically linked,
  • Portable data systems allow existing documentation to be converted into an electronic
  • patient data e.g., name, insurance provider, etc.
  • portable format e.g., a portable data
  • a centralized data system does not coordinate and link the various disparate types of data involved in a health-related transaction (e.g., identification
  • the present invention is directed to a method, system, and network for coordinating the communication of data in a health network (such as, for example, an Intelligent Card
  • a processor creates and maintains an electronic record of a health-
  • All data for a health-related transaction is thus collected, linked, and made available to relevant members of the health network in accordance with the present invention.
  • the electronic record (and thus all activity relating to the health-related transaction) is
  • the present invention simply and efficiently coordinates the communication of data in a health network, and between the health network and a banking network, for a health-related
  • the present invention thus provides electronic data linkage of all activity in a health-related transaction; electronically linking an insurance provider, a health plan, health care
  • claim submittal and reconciliation i.e., insured co-payment and insurance provider claim
  • the present invention ensures that data relating
  • invention creates an electronic record of activity relating to that health-related transaction.
  • the electronic record may be a single file containing all data for the health-related transaction.
  • the electronic record may be a pseudo case file
  • each database containing a plurality of pointers to a plurality of databases, with each database containing
  • the embodiment of the electronic record is preferably transparent to members of the health network within which the present invention is
  • the data included in the electronic record may include, by way of non-limiting example, a reference to: the insured; their insurance provider; each doctor visit and the
  • each laboratory visit and the service provided by the lab each hospital visit and the services provided by the hospital; each pharmacy visit and the prescription(s) dispensed;
  • a health network includes a processor that
  • the processor may be comprised of a computer or a plurality of connected and connectable computers having general purpose software (e.g., operating system, database creation and management, etc.) and special purpose software (defined by the desired functionality of the computer upon which the special purpose software is installed and operates). Communication by the processor to other computers, electronic devices, networks, etc.. may
  • general purpose software e.g., operating system, database creation and management, etc.
  • special purpose software defined by the desired functionality of the computer upon which the special purpose software is installed and operates.
  • network the Internet, wireless, or virtually any communication protocol, method, system,
  • Access to the processor by members of the health network may be via local land-
  • based or cell-based computing devices such as. for example, personal computers, site servers, identification card reading devices, hand-held computing devices (e.g. personal digital
  • member insurance providers may connect to
  • the processor via a site server located at the insurance provider.
  • the site server provides the functionality required for the insurance provider to operate and manage its health plans,
  • the site server provides a means for the insurance
  • a site server is not required for an insurance provider to access the processor.
  • Employers may also connect to the processor using employer computing devices (e.g., a personal computer). While providing less functionality than an insurance provider server,
  • the employer device enables the employer to modify eligibility data for employees by adding,
  • the employer computing device may upload such eligibility changes directly to the insurance provider site server which will, in turn, download the data to the
  • Each member of the health network is provided with an identification card that may be a magnetic card, a smart-card, or other portable device upon which data may be
  • the data provided on the card may include any combination
  • identification data e.g., allergies, physical/mental impairments, etc.
  • financial data e.g., bank identification number (BIN), personal identification number (PIN),
  • Health care providers may also connect to the processor via computing devices (e.g., smartphones, etc.).
  • the computing device for the health care providers may be an identification
  • card reading device such as, by way of non-limiting example, a magnetic card reader
  • the card reading device such as, for example, dual-swipe functionality, or that
  • functionality may be provided for in the magnetic card reader, or shared between the reader
  • the health provider computing device may be an identification card reading device connected to a personal computer or other functionally similar electronic device and which may include software for providing additional
  • the health care provider computing device may be configured for single- or dual- swipe card reading. For single-swipe functionality and for a magnetic card reader, a member insured may swipe his/her identification card through the reader, and that member's
  • identification data will be transmitted to the processor.
  • a member insured and a member health care provider may sequentially swipe their respective
  • the processor may identify the member using a look-up table, for example, and
  • the transaction also determine whether the transaction is a health-related transaction that should be routed to the health network, or a financial transaction that should be routed to the banking network.
  • the processor also links the insured identification number and the health care provider identification number for future use with regard to a particular health-related transaction.
  • the processor of the present invention is certified to create automated clearing house
  • ACH electronic funds transfer
  • EFT electronic funds transfer
  • the present invention provide benefits and advantages to insurance providers, health
  • benefits and advantages may include: increased efficiency and accuracy; reduced costs; reduced opportunity and occurrence of fraud; increased ability to generate provider and
  • EFT and payment reconciliation customized reports for health care providers, employers, and insured parties; electronic fund transfer and reconciliation; the ability to electronically link a specific health plan, health care provider(s), and insured party for each health-related
  • Health care providers may be paid more quickly because the time required for the insurance provider to review each case (which is currently a manual procedure) and authorize and
  • the benefits and advantages of the present invention may include: increased efficiency of the health deliver)' system; decreased cost of health care due to the
  • the following illustrative, non-limiting example describes a health-related transaction and how the present invention coordinates the communication of data in a health network
  • PCP primary care provider
  • identification data for the insured and PCP is transmitted, via their respective identification cards and the health care provider computing device, to the
  • processor which can determine, in real-time, the identity of the insured and PCP, and whether they are individually and collectively eligible under a predetermined insurance plan (that of
  • the processor recognizing that this is a new case, assigns a new (i.e.. original) authorization number to the case and transmits that authorization number to the PCP.
  • processor also creates and maintains an electronic record of all activity for the case; the record being keyed or based on the original authorization number.
  • the PCP may refer the insured to another health care
  • a referral authorization number is
  • PCP also communicates the referral authorization number to the insured.
  • the insured then proceeds to the referred health care provider.
  • the front office staff at the referred provider go through a process similar to that at the PCP, except that they indicate to the processor that the visit is a referral and provide the referral authorization
  • the referred office receives approval from the
  • the insured may return to the PCP for a follow-up visit.
  • the PCP communicates
  • a new claim authorization number is communicated by the processor to the PCP.
  • the PCP may later submit a claim for payment with the new claim authorization number and
  • the processor is configured for routing health-related transactions
  • a single identification card may thus be used for both health-related and financial transactions (and
  • One method of determining whether a transaction is health-related or financial is the number of identification cards swiped; a dual-swipe indicating a health-related
  • the insured may also elect to satisfy a co-payment obligation at the time the health
  • the care service is rendered by the health care provider.
  • the insured may elect to
  • the processor coordinates
  • the processor may receive a request from the insured, via the health care provider computing device, to electronically coordinate payment from the insured's bank account to the PCP's bank account.
  • processor may facilitate all aspects of that request, including formatting the request for
  • denial number is assigned by the processor to that transaction and included in the electronic record.
  • the PCP may submit claim payment requests to the insurance provider (via the processor) for each separate health-related transaction.
  • claim payment request is transmitted by the PCP along with the original transaction authorization number for that specific health-related transaction.
  • the processor may facilitate all aspects of the claim
  • payment request including formatting the request for communication to the banking network, communicating the formatted request to the insurance provider's bank, receiving approval or
  • the present invention also provides for pre-certification. For example, a health care
  • an insured may communicate with the insurance provider prior to an initial office visit, and obtain from the insurance provider authorization for the health care provider
  • That pre-approval may be accessed by the processor so that when the health care provider submits a claim for payment for those pre-
  • Fee-for-service relationships may also be managed by the present invention. For that
  • the insured is responsible for paying the health care provider, and that payment may be facilitated and effected by the present invention, as described in more detail below.
  • the health care provider submits a claim to the insurance
  • the insurance provider receives an authorization number, and the insurance provider pays the insured.
  • Health care services provided by out-of-network providers may also be authorized using the present invention by permitting the out-of-network provider to access the health
  • That electronic record links the various authorization numbers, insured identification number, insurance provider, health care provider(s), health care services, and financial transactions to a specific health-related
  • the present invention organizes, logs, coordinates, catalogs,
  • FIG. 1 is a schematic block diagrams of a representative health network having a processor and connected to a banking network in accordance with the present invention
  • FIGS. 2 A and 2B are schematic block diagrams of exemplar ⁇ ' preferred interconnections between and among the processor and members of the health network and the banking network in accordance with the present invention
  • FIG. 3 is a block diagram of an exemplary processor comprised of a plurality of
  • FIG. 4 depicts an exemplary relationship between and among the members of the
  • FIG. 5 depicts an exemplary interrelationship between and among the various components
  • FIG. 6 depicts an exemplary linkage provided by the processor in the electronic record for clinical data in accordance with the present invention
  • FIG. 7 depicts an exemplary linkage provided by the processor in the electronic record for financial data in accordance with the present invention.
  • FIG. 8 depicts a sample activity report for a health care provider in accordance with
  • FIG. 9 depicts a sample activity report for a patient in accordance with the present
  • FIG. 10 is a block diagram of an exemplary computing device including an identification card reader and connectable to the processor in accordance with the present
  • the present invention is directed to a method, system and network for coordinating the communication of data in a health network (referred to herein as an Intelligent Card
  • a processor creates and maintains an electronic record of a health-
  • authorization or transaction denial For example, all referrals, laboratory/hospital authorizations, prescriptions, payments, etc., are authorized or denied, with an appropriate
  • the electronic record (and thus all activity relating to the health-related transaction) is
  • the present invention simply and efficiently coordinates the communication of data in
  • a health network and between the health network and a banking network, for a health-related
  • the present invention thus provides electronic data linkage of all activity in a health-
  • the present invention ensures that data relating
  • the term members when used in reference to the health network, may include doctors (both primary care providers and specialists), laboratories, hospitals, ambulatory and out-patient treatment centers, pharmacies, insured parties, insurance providers
  • case and health-related transaction refer to the totality of
  • doctor visits including those to the primary care provider and specialists (i.e., referrals), laboratory visits, hospital and out-patent center visits, and the health care services provided at
  • payment to a health care provider may be for individual health services
  • care provider and the insured or the insurance provider, as the case may be, can be for the
  • present invention thus provides for line-by-line reconciliation by the health care provider and the insurance provider for the various health services provided by the health care provider.
  • FIGS. 1, 2A and 2B depict a health network 10 having a processor 100 and connected to a banking network 16 in accordance with the present
  • the processor 100 provides the functionality necessary to coordinate the communication of data in the health network 10, and between the health network 10 and the
  • the processor 100 may be any type of processor
  • the processor 100 may also include or be connected to a data storage device
  • the data storage device 170 may comprise RAID (Redundant Arrays of Independent Disks) level 5 arrays.
  • Those databases may include insurance provider identification data, health care provider
  • identification data health care provider computing device identification data, insured identification data, and other data, as needed, by the processor 100 to provide its desired
  • the communication of data in the health network refers generally to providing access
  • data refers generally to text, numerical, charts, pictures, graphics, voice (sound), images, video, and the like, that may be used between and among the insurance provider, the health care provider, the insured, an employer, and a financial services
  • Communication by the processor 100 to other computers, electronic devices, networks, etc. may be via a hardwired or routed network 12.
  • a dial-up or switched network 14 a virtual private network, the Internet, wireless,
  • the processor 100 may be any communication protocol, method, system, or device for facilitating such electronic communication as now known or as will later become known.
  • the processor 100 may be any communication protocol, method, system, or device for facilitating such electronic communication as now known or as will later become known.
  • processor 100 may be considered a virtual central processor in that the functionality provided by the various hardware and software components of the processor 100 appear to members of the health
  • network 10 to be centrally located. While that may be the case, the various hardware and
  • the health network 10 depicted in FIG. 1 includes a plurality of members including
  • a site server 200 may be provided as an interface between an insurance provider 20 and the processor 100, if desired. That site server
  • site server subsystem 210 comprised of general
  • the special purpose software is preferably customized for the insurance provider 20 and the site server subsystem 210 enables the
  • the site server 200 also provides the functionality for the site server 200 (and insurance provider
  • Access to the site server 200 by the insurance provider 20 may be via a computer 22 or a plurality of computers 22 linked via a local-area-network. Those
  • the computers 22 may provide the insurance provider 20 with administrative access to the site server 200 to enable the insurance provider 20 to change specific aspects of its various health plans (e.g., health plan rules, health provider eligibility, insured eligibility, authorized health care services, etc.).
  • the processor 100 preferably includes a mimic of the site server subsystem 210, to provide redundancy. The functionality provided by the processor 100 for each insurance provider 20 is customized based on the insurance provider's requirements.
  • the processor 100 may also be connected to one or a plurality of employers 30, each having a data entry terminal 32 (i.e., a computer) connectable to the processor 100 and to the
  • the employer 30 may add/delete
  • the changes may be transmitted only to the site server 200 or to the processor 100 which, in turn, respectively transmit the changes to the processor 100 or
  • Health care providers and insured parties that are members of the health network are each provided with a uni-functional identification card 250 or a multi-functional
  • identification card 252 depending on the needs of the particular party. Both types of
  • identification cards will be generally referred to herein using reference numeral 250, unless a specific card is intended, in which case its specific reference numeral will be used.
  • identification card 250 may be a magnetic card, a smart-card, or other portable device upon
  • identification card 250 is preferably a magnetic strip card of the type disclosed in U.S. Patent Number 6,000,608, the entire content and disclosure of which is hereby incorporated by
  • the data provided on the identification card 250 preferably provides only for identification of the card holder. However, additional information may be provided on the
  • the identification card may be a multi-functional card 252, usable for health-related, financial, and other types of transactions. Alternatively, the
  • identification card may be a uni-functional card 250. usable only for health-related
  • one card 250 may be
  • the processor 100 i.e., the eligibility subsystem
  • the data might include
  • That data might also include information about bank accounts related to the card (as in the case of a multi-function card)
  • the health care provider or the insured may also manually enter the identification card number (which may be printed or otherwise provided on the card) if card
  • the present invention facilitates that insured's change without the
  • the relative database(s) are merely updated in
  • the processor 100 to associate the insured with the new health plan or insurance provider. Similarly, if a new primary card provider is required, that change may be made at the
  • the processor 100 is further connected to one or a plurality of health care providers 60
  • Each health care provider 60 has a health care provider computing device 300 (see. e.g., FIG. 10) that may include general and special purpose software, and may be configured to communicate data from an identification card 250 to the processor 100
  • the provider computing device 300 may comprise an
  • identification card reading device 320 such as, by way of non-limiting example, a magnetic card reader, connected to the processor 100 that is configured for sequentially swiping
  • Reading device 320 is described below as a magnetic
  • reading device 320 may be any device for reading data from any type of data card, storage device, smart card, PDA, or
  • a health care provider 60 and an insured 90 may sequentially swipe their respective identification cards 250 through the card reading device 320 (or otherwise cause the data on the card to be sent to the processor 100) and their
  • the dual-swipe functionality for the card reading device 320 may be provided by software resident in the card reading device 320, software resident in the
  • processor 100 or a combination of both.
  • the health care provider computing device 300 may be an identification
  • card reading device 320 connected to a personal computer 310 (see, e.g., FIG. 10) or other
  • ICHN browser or other communication software
  • special purpose software for providing
  • the software resident in the card reading device 320 may also provide the dual-swipe, or other
  • the provider computing device 300 may be configured for single-swipe, dual-swipe, or either single- or dual-swipe functionality. When configured for single-swipe functionality, the provider computing device 300 permits an insured to swipe his/her identification card 250
  • the provider computing device 300 permits an insured and a health care provider to sequentially swipe their respective
  • identification cards 250 through the reading device 320 and their respective identification data will be transmitted to the processor 100.
  • the processor 100 may identify
  • the member using a look-up table, for example, and also determines whether the transaction is
  • the health care provider computing device 300 may
  • a stand-alone computing device e.g., a kiosk
  • the health network 10 i.e., to the processor 100
  • the health care provider's office computers i.e., to the processor 100
  • Access to the health network 10 and to the data provided thereby is also available to
  • the insured 90 using a personal computer and the Internet, for example.
  • the insured 90 thus provides a personal computer and the Internet, for example.
  • the processor 100 also connects to a banking network 16 comprised of a plurality of financial service providers 40. Since the processor 100 is configured to determine whether
  • incoming data is for a health-related transaction or for a financial transaction, the latter can be
  • Approval or denial of the requested financial transaction is provided by the financial service provider 40 to the processor 100,
  • the requesting party e.g., insured, health care provider, or insurance provider.
  • the processor 100 is preferably also designed to determine if a claim or claims have
  • the processor 100 is certified to create automated clearing house (ACH) and electronic funds transfer (EFT) files and transmit those files to financial service providers 40.
  • ACH automated clearing house
  • EFT electronic funds transfer
  • the processor can transmit financial transactions directly to the banking network 16 to satisfy co-payment obligations of the insured 90 and claim payment requests of the health
  • the processor 100 may comprise a main
  • LAN/WAN secure locator wide-area-network
  • satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software, providing for multiple redundancy. Alternatively, each of the main and satellite computers 104, 106 may be comprise identical hardware and software
  • processor 100 may be comprise hardware and software configured to provide a predetermined functionality of set of functionality of the processor 100. Although the functionality of the processor 100 may be
  • connection devices 60, insurance providers 20, and employers 30, may be via virtually any land-based or wireless connection device, system, or method, as a routine matter of design choice.
  • processor 100 i.e. health network 10
  • banking network 16 is preferably
  • the health network 10 and processor 100 of the present invention also facilitate visits
  • insured 90 may be entitled to reimbursement from the insurance provider 20, but the non-
  • member health care provider 180 is paid directly by the insured 90 and does not submit a claim to the insurance provider 20.
  • the insured's identification card 252 may be used to
  • processor 100 will facilitate that financial transaction and reconcile reimbursement by the
  • the insurance provider 20 to the insured 90 by communicating a claim for reimbursement to the insurance provider 20.
  • the insurance provider 20 has access to all data for the
  • FIG. 2B Data flow within the health network 10 as coordinated by the processor 100 is depicted in FIG. 2B.
  • Bi-directional data communication occurs between the processor 100 and insurance providers 20 (identified as “Health Plan” in the figure), financial service providers 40 (identified as “Bank” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), financial service providers 40 (identified as “Bank” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), financial service providers 40 (identified as “Bank” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), and the health care provider 60 (identified as “Health Plan” in the figure), and the health care provider 60 (identified as “Bank” in the figure), and the health care provider 60 (identified as “
  • communication may be from the processor 100 and include health-related transaction data received by the processor 100 from a health care provider 60, and database updates from the
  • communication may be from the insurance provider 20 to the
  • processor 100 and include health plan changes and database updates.
  • communication may be from the processor 100 and may include
  • financial transaction data such as, for example, ACH and EFT files, or it may be from the financial service providers 40 to the processor 100 and may include authorization and/or acknowledgement of completion of a requested financial transaction.
  • financial transaction data such as, for example, ACH and EFT files, or it may be from the financial service providers 40 to the processor 100 and may include authorization and/or acknowledgement of completion of a requested financial transaction.
  • providers 60 communication may be from the provider 60 to the processor 100 and may
  • Communication to the health care provider 60 by the processor 100 may include
  • authorization data information from another health care provider and clinical data.
  • Communication from the processor 100 to the insured 90 may include that insured's account
  • the processor 100 the processor functionality may be
  • subsystems 1 10, 120, 130, 140, 150, 160 each providing a particular functionality or set of functionalities, as described in more detail below. While particular preferred embodiments of the processor 100 and associated subsystems as taught
  • the health care network 10 may be different for different insurance providers, and may change as the needs of the health care network 10 change (i.e., subsystems may be modified, added, and/or deleted).
  • subsystems may be modified, added, and/or deleted.
  • the processor preferably has a plurality of subsystems, including, but not limited to: a host subsystem 110; a communication subsystem 120; an
  • the Host Subsystem 1 10 provides overall control of the processor 100 and health
  • network 10 communicates with the other subsystems of the processor 100, and controls and electronically links all activity for the health-related transaction. That electronic linking
  • the host subsystem 1 10 establishes an audit trail by creating and maintaining an audit trail
  • Transactional access and transactional data respectively refer to access to the processor 100 and/or any subsystem during a health-related transaction, and any data (e.g.,
  • access refers to access by a system administrator to the processor 100 and/or
  • any subsystem to manually change data e.g., insurance provider changes health plan rules
  • the electronic record may include the date, time, user identification or terminal identification, and an indication of
  • the host subsystem 110 coordinates access to the data storage device 170 and to the databases stored thereon.
  • Those databases may include data used by the processor 100 (by
  • the data in the databases may be provided by the insurance providers, employers, health care providers, financial service providers, and the insured. Some of that data is updated automatically, while some data is updated manually. For
  • changes by the insurance provider in health plan data are automatically uploaded by the insurance provider site server 200 to the processor 100 via the host subsystem 110.
  • the host subsystem 1 10 automatically uploads/downloads data to and from the site servers 200 and health care provider computing devices 300 via the communication
  • the host subsystem 110 may, in addition, handle all authorizations for access to the data contained in the plurality of databases on the data storage device 170.
  • the host subsystem 1 10 also creates and maintains an electronic record that links all activity associated with a specific health-related transaction. That electronic record may be
  • the electronic record links all transactions (activity) associated with one health- related transaction or case and permits the processor 100 to treat that record as a pseudo case file that may be communicated, in whole or in part, to members and within the health network
  • the database structure of the pseudo case file may contain a field, or several fields if
  • FIGS. 4 - 7 An illustrative example of the electronic record and linkage provided in accordance with the present invention is depicted in FIGS. 4 - 7, and discussed in more detail below.
  • the host subsystem 1 10 also communicates with the eligibility subsystem 130 and passes all transactional data received by the processor 100 to the eligibility subsystem 130
  • identification data received by the host subsystem 1 10 is communicated to the eligibility subsystem 130.
  • the eligibility is communicated to the eligibility subsystem 130.
  • the subsystem 130 accesses a database of member identification data on the data storage device 170 and determines if the member is an eligible member.
  • the processor 100 further maintains or has access to a list of active insured 90, health care providers 60, and health care provider computing device 300 identification numbers for each insurance provider 20 and for
  • processor 100 that any of the insured 90, health care provider 60, or health care provider
  • the host subsystem 1 10 shall cause the communication subsystem 120 to terminate the connection to the health care provider computing device 300.
  • the host subsystem During the initial authorization/eligibility determination process, the host subsystem
  • the host subsystem 110 links the
  • the host subsystem 1 10 also communicates with the financial subsystem 140.
  • data received by the processor 100 is determined to be a purely financial transaction, that data
  • ACH or EFT file created may be formatted (e.g., an ACH or EFT file created) and communicated directly to the financial subsystem 140 for transmittal to the financial service provider 40 via the banking
  • a purely financial transaction may include, by way of non-limiting example, a request from the insured 90 for co-payment to a health care provider 60, receipt by the
  • the host subsystem 1 10 may also receive data from the financial subsystem 140
  • denial from the financial service provider 40 are linked to the electronic record as part of the activity for the health-related transaction.
  • the host subsystem 1 10 may, upon request, furnish
  • the host subsystem 1 10 also communicates with the replication subsystem 150 so that
  • financial service providers 40 is available in real-time throughout the health network 10. The
  • replication subsystem 150 may identify changes in database records relating to an insurance
  • the host subsystem 110 may either receive change data and update the replication system 150
  • the replication subsystem 150 may send change data to the host subsystem 1 10 for communication to relevant devices (e.g., site server 100, financial service
  • the host subsystem 1 10 also communicates with the administration subsystem 160 to
  • network administration such as for example, data backup, may be coordinated by the host subsystem 110 according to parameters and conditions defined by the administration subsystem 160.
  • the host subsystem 110 may also build data sets for export and use by other entities.
  • the host subsystem may be subsystems or by other computers within or out of the health network 10.
  • the host subsystem may be implemented by any combination of
  • 1 10 may also coordinate the generation of ad hoc reporting such as a health care provider or insured activity report. Standard and customized reports may be developed and generated, as a routine matter of design choice. For example, an insurance provider may require monthly
  • the general purpose software provided as part of the processor facilitates building database structures, database content, and creating, rebuilding, or repairing database indices.
  • Visual FoxPro SQL Server, Access, Visual Basic, or Visual C++, or
  • Transaction processing refers to the communication of data within the health network
  • Transaction processing includes creating and
  • This electronic record may include the date, time, member and/or computing device identification number, and an indication of what data was altered and how it was
  • Transaction processing also refers to receiving data from and sending data to the
  • transaction type field e.g.. health-related or financial
  • the content of the transaction type shall result in data being forwarded to the appropriate processing function for action (e.g., to the financial subsystem
  • Data sent to the communication subsystem 120 shall
  • This data preferably includes a destination identifier (i.e.,
  • the host subsystem 1 10 maintains a database of valid health care provider computing
  • the host subsystem 110 interrogates this database to determine if that health care provider computing device 300 has access rights to
  • the host subsystem 110 causes the communication
  • the host subsystem 1 10 operates as a gateway for all authorizations for access to the
  • Rights to access the data contained in the storage device 170 shall be assigned to authorized subfunctions as necessary to maintain the
  • the eligibility subsystem 130 performs rules-based testing on each insured 90 and
  • the eligibility subsystem 130 performs tests on the transactional data received from the host subsystem 110 using specific insurance policy and
  • Health network data provided by the insurance providers 20 may be provided by multiple instances of the eligibility subsystem 130, to accommodate multiple insurance provider eligibility rules.
  • the eligibility subsystem 130 determines eligibility for the insured, health care
  • the eligibility subsystem 130 receives data from the host
  • This data may include transactional records to be tested to determine if the
  • insured 90 is eligible to receive health care services and if the health care provider 60 is
  • the eligibility subsystem 130 will preferably be capable of sending data to the host subsystem 1 10. That data may be comprised of, for
  • authorization or denial information as determined by the appropriate subsystem.
  • the eligibility subsystem 130 for each insurance provider 20 There are generally two major subdivisions of the eligibility subsystem 130 for each insurance provider 20: the insured and the health care provider authorization, which may be
  • the policy data provided by the insurance provider 20 can be used to determine if the insured 90 is currently covered by a health plan.
  • the rules-based eligibility test may include a test of the current validity of the plan itself as well as the insured's current participation in the plan, the applicable coverage for that insured under that plan, and any financial and/or temporal limitations. Up-to-date data is
  • the replication subsystem 150 ensures that changes to any of the data maintained and used by the processor 100, insurance providers 20, employers 30, and financial service providers 40, is
  • PCP primary care provider
  • the health care provider 60 and the insured 90 shall be forwarded to the provider's health care
  • network 10 will preferably not cause emergency services to be denied (unless, of course, the insurance provider's 20 contract explicitly orders such a denial).
  • the eligibility subsystem 130 may determine eligibility for any type of insurance provider 20 offering any type of health plan.
  • an insurance provider 20 may offer insurance under a variety of health plans, e.g., HMO, etc.
  • Different rules provided by the insurance provider 20
  • the insurance provider 20 may be applied by the eligibility subsystem 130 for the different reasons
  • referral visits will require the use of a previously issued referral authorization number or code.
  • a previously issued referral authorization number or code may, for example, be provided by the processor 100 to the PCP, and communicated by the PCP to the insured 90. Also, a provision shall be made to retrieve the referral authorization number from the referred
  • the referral authorization number may be retrieved from the referred health care provider 60 by using the PCPs' identification number and the insured's identification number; those two data being part of the electronic record and
  • the eligibility subsystem 130 may be provided
  • the main processor 104 will coordinate the distributed functionality of the eligibility subsystem 130.
  • the eligibility subsystem 130 may utilize data provided by the insurance provider 20. That data may be provided in real-time or previously downloaded
  • the processor 100 shall provide notice that the cost of any services provided may not be paid by the insurance provider 20 and a transaction denial number is
  • eligibility subsystem 130 shall deny all such service requests.
  • the communication subsystem 120 facilitates communication between the processor 100 and the health care provider computing device 300, and the insured 90. Since all of the health care provider computing devices 300 are part of the health network 10, those
  • computing devices 300 will preferably employ the same communication techniques and
  • the communication subsystem 120 may be adaptable to enable communication between the processor 100 and a device, system, etc. that employs a different communication technique or protocol.
  • the communication subsystem 120 may receive data from the health care provider
  • computing device 300 including, but not limited to, transactional data for communication to
  • the host subsystem 1 10 so that such transactional data may be properly routed (e.g., to the
  • the communication subsystem 120 may also transmit data to the health care provider computing device 300. That data may
  • the communication subsystem 120 may include voice response
  • the communication subsystem 120 may receive data that may consist of, for example, numerical responses or voice
  • the communication subsystem 120 shall authenticate (in connection with the eligibility subsystem 130) the insured's identity and access permission. 4. Financial Subsystem
  • the financial subsystem 140 facilitates communication between the processor 100 and
  • Transactional data received by the processor 100 for a purely financial transaction may be formatted by the financial subsystem 140 (e.g., an
  • the transactional data is for a health-related transaction yet includes a financial transaction request (e.g., co-payment, claim settlement)
  • the data is communicated to the financial subsystem 140 for processing. That processing may include proper formatting, transmission
  • the financial subsystem 140 may facilitate the electronic transfer of funds from an
  • the financial subsystem 140 may also facilitate the electronic transfer of funds from the
  • the financial subsystem 140 may have access to a list of pre-approved health care
  • ACH file may be automatically create and transmit an ACH file to the appropriate bank thus permitting that bank to transfer the necessary funds directly to the health care provider's bank. That activity is captured by the host subsystem 110 and included in the electronic record. Various tags may be assigned to specific transactions by the financial subsystem 140. Authorized co-payments may be tagged as received, denied co-payments tagged as denied,
  • the replication subsystem 150 maintains database synchronization throughout the health care network 10. More specifically, the replication subsystem 150 ensures that all database changes, whether initiated by the processor 100, insurance provider 20, or employer
  • the replication subsystem 150 may automatically transmit and receive data to and from the site servers 200 or according to a predetermined
  • One instance of the replication subsystem 150 may be necessary to communicate with each site server 200.
  • the replication subsystem 150 may receive data from the host subsystem 1 10. That is
  • data may be, by way of non-limiting example, database records requested from the host subsystem 1 10 for transmission to the site servers 200.
  • the replication subsystem 150 also serves to store data from the host subsystem 1 10 for transmission to the site servers 200.
  • the replication subsystem 150 may also, in a preferred embodiment, decrypt and expand database records that have been received in encrypted and/or compressed form from
  • the replication subsystem 150 may also, if desired, compress and encrypt database records which are to be sent to the various site servers 200 to ensure
  • the replication subsystem 150 preferably maintains a log of all communication between the processor 100 and the site
  • the replication subsystem 150 may also transmit data to the site server(s) 200 such as, for example, synchronization records, synchronization requests, and real-time co-payment
  • the replication subsystem 150 may also send
  • the replication subsystem 150 preferably has the functionality
  • the administration subsystem 160 provides the graphical user interface (GUI) to the GUI.
  • GUI graphical user interface
  • This subsystem can either be locally or remotely accessed for administrative purposes.
  • the administration subsystem 160 communicates with and can send, receive, and process data from the host subsystem 110. That data may include responses to administrative
  • administration subsystem 160 may send data to the host subsystem 110 including, updates to
  • master database records, requests for data, requests for status, and log data for maintenance use.
  • the processing may include health plan changes, member changes, policy changes, suspensions, deletions, warnings, password changes, and other such requests.
  • the administration subsystem 160 may process diagnostic tests and provide data about the
  • each health care provide 60 is equipped with a health care
  • provider computing device 300 that may comprise an identification card reading device 320
  • processor 100 such as, by way of non-limiting example, a magnetic card reader, connected to the processor 100.
  • software at the processor 100 may provide additional
  • the card reading device 320 such as, for example, dual-swipe functionality.
  • the health provider computing device 300 may be an identification card reading device 320 connected to a personal computer 310 or other functionally similar electronic
  • Communication between the computing device 300 and the processor 100 may be via modem 350, for example, or via virtually any
  • the health care provider computing device 300 preferably has one or more of the
  • a display 340 such as, for example, a liquid crystal, liquid plasma, or light emitting
  • diode display a keypad 330; a magnetic strip reader 320; and a modem 350, or other art- recognized communication device.
  • the modem 350 may be used by the computing device 300 to dial or otherwise
  • the modem 350 may answer incoming calls and receive data from the communication subsystem 120.
  • a "secret" key received and recognized by the modem 350 will ensure authorized connection with the calling device or system (i.e., the processor 100). If the key is not received or recognized, the line shall be dropped. A record will be kept of these
  • the computing device 300 shall automatically lock-out incoming calls, requiring manual intervention to
  • the data received by the computing device 300 may include, for example,
  • protocol messages for example, protocol messages, uploaded programs, and uploaded database records.
  • the special purpose software provided on the computer 310 is preferably
  • the special purpose software also has access to the manufacturer's embedded serial number for the card reading device 320, and may communicate that serial number as a computing device
  • the computing device 300 can optionally maintain a database in its internal memory
  • the database may be
  • the database may be maintained for no less than one previous day's transactions, or as many days as are desired, as a matter of application specific
  • the site server 200 include a resident site server subsystem 210 that is customized for each insurance provider 20 and that provides the functionality to enable the insurance
  • provider 20 to operate and manage all aspects of each health plan offered by that provider 20. including functionality for interfacing with any legacy computer systems of the provider 20.
  • a duplicate of the site server subsystem 210 is provide within the health network 10 and
  • the site server subsystem 210 may include all or some of the
  • the starting point for the electronic data linkage is the insured's initial visit to the PCP. At that visit, if both the insured and PCP are eligible members of a health plan, the processor 100 provides an original authorization number that becomes a
  • processor 100 for various uses.
  • FIGS. 1 , 3, 5, and 10 an illustrative, non-limiting example of how the electronic data linkage and preferred data flow is carried out in accordance with the present invention is there depicted.
  • the labels and codes are merely exemplary, and may be implemented in myriad ways as a matter of application specific design choice. That depiction is for a typical series of office visits to a PCP and three referred health care
  • exemplar ⁇ ' parties i.e. participants
  • a health-related transaction or at least a part of a health-related transaction
  • Ref 3 a third referred provider; and references to all activity for the health-related transaction, represented by authorization numbers, and that may comprise a part of the
  • the health-related transaction begins in the insured column, with the activity at the
  • the insured 90 may elect to pay for the health care services using his/her
  • identification card 250 by swiping the card 250, enter a PIN, and selecting to pay for services, or pay co-pay, through processor 100. That payment request is communicated to the financial
  • the insured may have previously authorized co-payment to the health care provider.
  • the PCP refers the insured to three different providers. This is indicated by the series of activities beginning with the "Ref 1 " box in the Primary
  • PCP provides the processor 100 with the original transaction authorization
  • processor 100 finds no reason to deny the referral, it is "OK" and a referral authorization
  • the PCP's office enters the list of services provided to the insured. This is again identified with the original transaction authorization number (123450).
  • the processor 100 provides a return approval code 123450C to the PCP.
  • the insured in the interim, has appeared at the first referred provider indicated by the circle in the Insured column marked "2".
  • the front office staff at the referred provider goes through a process similar to that at the PCP, except that they indicate to the processor 100 that the visit is a referral and provide the referral authorization number (123451) the insured
  • the referral office receives an '"OK" from the processor 100 and is provided with a claim authorization number (123454) for use in their later
  • Linked Database record pointers This line is meant to indicate that the processor 100 has created and maintained (linked) an electronic record of all activity for the health-related
  • processor 100 and tagged with the authorization number, date, time, and other important information. When this data is needed later, the complete chronology of the activities and the
  • associated data can be recalled as a pseudo case file similar to the paper files maintained at the health care providers' and insurance providers' offices.
  • the insurance provider 20 may then choose to pay for claims via the processor 100 by authorizing the electronic payment of specific claims, or multiple claims and using the authorization code(s) to direct the processor 100 to transmit to the appropriate financial service provider 40 a request for EFT.
  • the processor 100 links the claim payment request to the original transaction authorization number, and the referred health care provider's bank receives the funds from the insurance provider's bank.
  • the referred provider also receives an
  • Illustrative activity reports that may be produced by the processor 100 using all or part
  • FIGS. 8 and 9 depicted in FIGS. 8 and 9 for a health care provider and an insured, respectively.
  • line-by-line reporting
  • provided to the insured may include information in addition to that for health-related transactions.
  • the insured 90 is provided with a multi-function card 252
  • the insured's activity report such as, for example, debit card, prepaid phone card, loyalty card, and gift certificate card activity.
  • FIGS. 6 and 7 The data linkage provided by the electronic record in accordance with the present invention is depicted in FIGS. 6 and 7 for clinical data and financial data, respectively. For each example depicted, all subsequent activity is linked to the original transaction
  • the clinical data communicated between health care providers is secure in that only the insured's identification number is transmitted along with the clinical data; there is no identifier or means of linking the clinical data with the actual insured 90 until the
  • the clinical data thus merely passes through the processor 100, encoded or encrypted, thus
  • an original transaction authorization number 0005000 is provided by the processor 100 following an initial eligibility determination for the
  • referral authorization numbers 0005001 A and 0005002 may also be provided by the processor 100, thus authorizing the
  • the provider and insured both swipe their respective identification cards, and the processor thus links that visit, those parties, and the referral authorization number to the original transaction authorization number 0005000 together in
  • the insured 90 may also return to the primary care provider 60, with that visit being
  • authorization number 00050003 when than is also linked by
  • Clinical data communication in accordance with the present invention is also depicted in FIG. 6.
  • a primary care provider desires a referred care provider to perform certain tests, procedures, etc.
  • the primary care provider may transmit a request for information (RFI)
  • That RFI may include specific instructions regarding tests, information, etc., that the primary care provider desires the referred care provider to obtain.
  • Also transmitted with the RFI may be clinical data for a particular insured. However, nowhere in the transmission is there any identifier for the insured. Only the original
  • the referred care provider cannot link that data to a person until the insured provides his/her identification number during an office visit with the referred care provider. At no time is any insured identification data transmitted with clinical data.
  • the electronic record may also include a
  • the processor 100 ensures (via the replication subsystem) that the insurance
  • insured parties may be provided with a written statement or an electronic statement of that members activity relating to a health plan for a predetermined time period or health-related transaction.
  • Electronic statements may be transmitted by the processor 100 to the member using the Internet or other means of electronic transfer, or through a voice response unit (not shown).
  • the data may be provided in a monthly statement similar to the
  • the identification card 250 and the health network 10 constructed in accordance with the present
  • the processor 100 of the present invention enables a member to change health plans

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  • Engineering & Computer Science (AREA)
  • Health & Medical Sciences (AREA)
  • General Health & Medical Sciences (AREA)
  • Epidemiology (AREA)
  • Biomedical Technology (AREA)
  • Medical Informatics (AREA)
  • Primary Health Care (AREA)
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  • General Physics & Mathematics (AREA)
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Abstract

L'invention concerne un procédé, un système et un réseau pour coordonner la communication de données dans un réseau de santé, et entre ce réseau de santé et un réseau bancaire pour assurer une transaction liée à la santé. Selon la présente invention, un processeur (100) crée et gère le suivi de l'enregistrement électronique d'une transaction liée à la santé en fournissant ou en transmettant une autorisation de transaction initiale ou un refus de transaction pour cette transaction liée à la santé. Toutes les activités nécessaires à cette transaction sont reliées, par voie électronique, via l'enregistrement électronique, à l'autorisation de transaction initiale ou au refus de transaction. Selon la présente invention, il est possible de mettre à disposition, en temps réel, pour les parties de cette transaction, toutes les données et les actions requises pour assurer cette transaction. La présente invention traite également d'une conciliation proportionnelle entre l'assureur, le fournisseur de soins de santé (60), un assuré (90) et un prestataire de services financiers. La présente invention assure la transmission sécurisée de données cliniques ou d'autres données importantes du patient (ou de l'assuré)(90) entre les fournisseurs de soins de santé (60) et les autres participants du réseau santé.
PCT/US2000/012331 1999-05-04 2000-05-04 Procede, systeme et reseau permettant de coordonner la communication de donnees pour une transaction liee a la sante WO2000066367A1 (fr)

Priority Applications (1)

Application Number Priority Date Filing Date Title
AU48229/00A AU4822900A (en) 1999-05-04 2000-05-04 A method, system and network for coordinating the communication of data for a health-related transaction

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US13249999P 1999-05-04 1999-05-04
US60/132,499 1999-05-04

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US10262374B2 (en) 2011-05-18 2019-04-16 Cognizant Trizetto Software Group, Inc. System and method for processing payment bundles
US10937106B2 (en) 2011-05-18 2021-03-02 Cognizant Trizetto Software Group, Inc. System and method for processing payment bundles
US10296976B1 (en) 2011-09-23 2019-05-21 Cognizant Trizetto Software Group, Inc. System and method for calculating estimated payment based on partial coding data
US10318923B1 (en) 2012-08-01 2019-06-11 Cognizant Trizetto Software Group, Inc. Payment assurance and claim pre-validation
US10733567B2 (en) 2012-08-01 2020-08-04 Cognizant Trizetto Software Group, Inc. Payment assurance and claim pre-validation

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