Abstract: A claim valuation engine is provided. The claim valuation engine enables a healthcare provider to accurately value an expected reimbursement of a claim from a payer based on a contract between the healthcare provider and the payer. Contract terms, code sets, fee schedules, and other valuation data is input into the engine. The engine receives a claim from a healthcare provider information system, locates a contract applicable for valuing the claim, correlates the claim attributes with the contract terms according to a hierarchy, and determines an expected reimbursement for each claim attribute or group of attributes. The claim valuation engine is further operable to determine contractual allowances, determine under and overpayments by validating remittances, and to simulate valuation of a contract by valuing a claim based on multiple sets of contract terms. The engine is further operable to generate output reports and post results to the healthcare provider information system.

Abstract: Proactive resolution of coordination of benefits (COB) issues is provided. Payer data is received as membership files from a plurality of payers, the payer data including eligibility and member demographic data. Upon detection of new or modified information, a normalizing engine may be utilized to normalize name information, address information, and social security number information into a format for comparing with other stored payer data according to various rules. A matching engine may be utilized to compare the normalized payer data against other insurance provider data to determine COB instances by discovering matches or partial-matches of member information. A set of rules may be applied to determine a primary versus a secondary payer. An output file, which may comprise matches and COB determinations, raw data, and a web interface for accessing archived reports and files and to generate individual member searches, may be provided to one or more payers.

Abstract: Validating patient payment estimates is provided. Validating patient payment estimates may comprise matching patient payment estimates with claims, payments and insurance contracts and providing tools to analyze the results of the matching process. Discrepancies may be determined, for example discrepancies between procedures and patient portions from the estimate with procedures actually billed and paid and a patient portion determined by the insurance company. Results may be stored in a dashboard user interface, which may then be available via a user interface for drill-down analysis.

Abstract: Consistently coded eligibility data is provided. Eligibility responses may be received from various payers comprising inconsistently coded eligibility benefit (EB) information provided in EB segments in various locations in the responses. A data restructuring engine may be operable to receive an eligibility response and restructure the response into a consistent format. Co-pay, co-insurance, benefit limitations, and benefit specific deductibles may be clarified by embedding coded strings in one or more message segments attached to EB segments. Service types, network indicators, place of service codes, and message text may be removed when a coded strings is created. Recoded eligibility responses may be provided to healthcare providers, providing coverage, eligibility, and benefit data in a consistent and standardized form, regardless of the payer sending the eligibility response.

Abstract: Account prioritization for a patient access workflow is provided. The patient access workflow may be an exception-based integrated workflow. An indication of discrepant data, missing data, or input/user-interaction that may be needed for performance of a patient access workflow process for a patient account may be provided via alerts displayed in an integrated user interface. A prioritization engine may determine a priority score for a patient account based on various determining factors and weightings applied to each determining factor. The patient account may be placed in a queue of accounts needing to be cleared in order by priority score, such that when a user selects to receive a next account to clear, the account with the highest priority score may be provided to the user. Accordingly, a user may be able to address and resolve alerts to ensure patient access workflow processes are performed prior to a healthcare encounter.

Abstract: An assembly management system allows a software service provider (SSP) to compile and upload client-specific client application code into a repository. The SSP deploys a client application comprising non-client-specific code to various clients. When a user logs in, a call is made to a web service, which queries the repository for code specific to the requesting client. If available, the web service sends a response with the name and version of the assembly to which the client is subscribed. If the locally-saved version does not match the version of the assembly in the repository, and if the SSP has permission to write to the client's disk, the web service retrieves the assembly and commits it to the disk. If the SSP does not have permission, the assembly is streamed to the client device and retained and executed in memory for the duration of the login.

Abstract: Eligibility benefit information associated with a subscriber or dependent may be requested by a provider in an eligibility request, for example, a 270 request. Embodiments may intelligently determine a most appropriate service type code (STC) for a provider's eligibility request based on their location (“where”) and on the provider type (“who”). Utilizing precision STC tables for a payer (“what”) and the identity of the “who” and “where” associated with the provider sending the request, appropriate component level (and if needed, explicit level) STCs may be submitted in an intelligent eligibility request. Accordingly, an appropriately detailed yet focused response to the request may be received.

Abstract: An automatic medical coding system is provided. The system parses features of natural language diagnosis and procedure information. The features are compared to elements of a medical coding system. Medical codes corresponding to medical coding system elements that match features of the diagnosis and procedure information are mapped to the received diagnosis and procedure information. The mapped medical code is assigned a score reflecting the estimated reliability of the mapped medical code based on the amount of manipulation of the received diagnosis and procedure information leading to the match. The scored medical code may be submitted to a workflow making use of medical codes. The scored medical code may optionally be presented to a user for review prior to further utilization of the scored medical code.

Abstract: An assembly management system allows a software service provider (SSP) to compile and upload client-specific client application code into a repository. The SSP deploys a client application comprising non-client-specific code to various clients. When a user logs in, a call is made to a web service, which queries the repository for code specific to the requesting client. If available, the web service sends a response with the name and version of the assembly to which the client is subscribed. If the locally-saved version does not match the version of the assembly in the repository, and if the SSP has permission to write to the client's disk, the web service retrieves the assembly and commits it to the disk. If the SSP does not have permission, the assembly is streamed to the client device and retained and executed in memory for the duration of the login.

Abstract: An ability to expose and display a current billing amount associated with a billing account in a billing system to one or more third parties, and to link one or more payments from the one or more third parties to the billing account in an account receivable system is provided. A user may create, publish, and share a fundraising webpage, which when accessed by a third party, allows the third party to send a payment in the form of a contribution or donation. An intermediary system allows for secure communication of billing account data from the accounts receivable system to the third party, allowing the third party to interact with the accounts receivable system as if the third party is in direct communication with the accounts receivable system.

Abstract: Encrypting data without losing their format is important in computing systems, because many parties using confidential data rely on systems that require specific formatting for data. Information security depends on the systems and methods used to store and transmit data as well as the keys used to encrypt and decrypt those data. A policy broker is disclosed that maintains keys for clients in confidence, while providing cryptographically secure ciphertext as tokens that the clients may use in their systems as though they were the unencrypted data. Tokens are uniquely constructed for each client by the policy broker based on policies set by a receiving client detailing the formatting needs of their systems. Each client may communicate with other clients via the policy broker with the tokens and will send tokens unique to their system that the policy broker will translate into the tokens of the other party.

Abstract: Systems and methods for improved detection of fraud, waste, and abuse are provided, based on the analysis of enriched relationships and aggregated metrics thereof. An enriched relationship record associates patient and provider information to provide an enhanced view of patient data, provider data, and interaction data for a given entity. Aggregated metrics provide an enhanced view of a particular entity's activities based on the entity's interactions with other entities and data and metadata from the related entities' enriched relationship records. The enriched relationship records and aggregated metrics may be used to audit the entity and produce a report indicative of suspicion levels for the entity engaging in fraud, waste, or abuse.

Abstract: Dynamically determining an optimum connectivity path is provided. Default paths to connectivity sources associated with a payer may be determined and ranked based on various metrics, such as availability, content, and cost. When a connection to a primary connectivity source is determined to be down or unresponsive, a request may automatically be routed to a next connectivity source, wherein the next connectivity source is determined to be a next highest ranking connectivity source based on the various metrics. Data associated with availability, content, cost, and other attributes may be collected, stored in a database, and utilized to rank connectivity sources. Accordingly, as new information about a payer or connectivity source is discovered, default paths and rankings of connectivity sources may change.

Abstract: An assembly management system allows a software service provider (SSP) to compile and upload client-specific client application code into a repository. The SSP deploys a client application comprising non-client-specific code to various clients. When a user logs in, a call is made to a web service, which queries the repository for code specific to the requesting client. If available, the web service sends a response with the name and version of the assembly to which the client is subscribed. If the locally-saved version does not match the version of the assembly in the repository, and if the SSP has permission to write to the client's disk, the web service retrieves the assembly and commits it to the disk. If the SSP does not have permission, the assembly is streamed to the client device and retained and executed in memory for the duration of the login.

Abstract: Keeping track of which communications are related, or linked, in a series of communications is an important feature in many electronic document systems. As communication chains grow and branch, however, these systems require meticulous use of unique document identifiers to maintain those links. Systems and methods to create or restore these links in the absence or misuse of unique document identifiers are therefore provided. Responsive communications from parties are linked with the initial communications whose requests are answered by the responsive communications. Additionally, any requests not answered by the responsive communications may be automatically configured into a secondary communication which will be linked with the responsive communication and the initial communication so that its responsive communication may be built into the chain of communication.

Abstract: An assembly management system allows a software service provider (SSP) to compile and upload client-specific client application code into a repository. The SSP deploys a client application comprising non-client-specific code to various clients. When a user logs in, a call is made to a web service, which queries the repository for code specific to the requesting client. If available, the web service sends a response with the name and version of the assembly to which the client is subscribed. If the locally-saved version does not match the version of the assembly in the repository, and if the SSP has permission to write to the client's disk, the web service retrieves the assembly and commits it to the disk. If the SSP does not have permission, the assembly is streamed to the client device and retained and executed in memory for the duration of the login.

Abstract: Encrypting data without losing their format is important in computing systems, because many parties using confidential data rely on systems that require specific formatting for data. Information security depends on the systems and methods used to store and transmit data as well as the keys used to encrypt and decrypt those data. A policy broker is disclosed that maintains keys for clients in confidence, while providing cryptographically secure ciphertext as tokens that the clients may use in their systems as though they were the unencrypted data. Tokens are uniquely constructed for each client by the policy broker based on policies set by a receiving client detailing the formatting needs of their systems. Each client may communicate with other clients via the policy broker with the tokens and will send tokens unique to their system that the policy broker will translate into the tokens of the other party.

Abstract: Improvements to the process of providing patient assistance to conform with prescribed courses of treatment are provided. Providing assistance based on patient-specific data is implemented via an assistance analyzer communicated with a processing clearinghouse, and the process of determining how to assist the patients in adhering to their courses of treatment at the time the prescription is filled, without the patient engaging in a separate process to apply for a discount. By applying the present disclosure, existing systems improve their sensitivity to patient need when providing time sensitive information, and may be configured to use fewer processing resources than before; improving the functionality of the systems themselves.

Abstract: Encrypting data without losing their format is important in computing systems, because many parties using confidential data rely on systems that require specific formatting for data. Information security depends on the systems and methods used to store and transmit data as well as the keys used to encrypt and decrypt those data. A policy broker is disclosed that maintains keys for clients in confidence, while providing cryptographically secure ciphertext as tokens that the clients may use in their systems as though they were the unencrypted data. Tokens are uniquely constructed for each client by the policy broker based on policies set by a receiving client detailing the formatting needs of their systems. Each client may communicate with other clients via the policy broker with the tokens and will send tokens unique to their system that the policy broker will translate into the tokens of the other party.

Abstract: Keeping track of which communications are related, or linked, in a series of communications is an important feature in many electronic document systems. As communication chains grow and branch, however, these systems require meticulous use of unique document identifiers to maintain those links. Systems and methods to create or restore these links in the absence or misuse of unique document identifiers are therefore provided. Responsive communications from parties are linked with the initial communications whose requests are answered by the responsive communications. Additionally, any requests not answered by the responsive communications may be automatically configured into a secondary communication which will be linked with the responsive communication and the initial communication so that its responsive communication may be built into the chain of communication.