SYSTEM AND METHOD FOR IDENTIFYING AND CONDENSING SIMILAR AND/OR ANALOGOUS INFORMATION REQUESTS AND/OR RESPONSES
A system and method for identifying and condensing similar and/or analogous information requests and/or responses comprising a computer apparatus having an intelligent global rules engine to facilitate interaction with information requests and/or responses. The computer apparatus comprises machine-readable medium, wherein data is stored, wherein the data comprises a comparison of similar and/or analogous information requests and/or responses, wherein redundancies and/or analogies in information requests and/or responses have been identified and condensed to remove the redundancies and/or analogies thereby creating at least one global rule, rule group and/or single rule. The computer apparatus further comprises both a data processing module, wherein the data processing module comprises a lexical analyzer with contextual awareness, and an intelligent global rules engine, wherein the intelligent global rules engine comprises the at least one global rule, rule group and/or single rules.
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To the full extent permitted by law, the present United States Non-provisional patent application is a Continuation application and hereby claims priority to and the full benefit of United States Non-provisional application entitled “SYSTEM AND METHOD FOR IDENTIFYING AND CONDENSING SIMILAR AND/OR ANALOGOUS INFORMATION REQUESTS AND/OR RESPONSES”, having assigned Ser. No. 13/874,244, filed on Apr. 30, 2013, incorporated herein by reference in its entirety.
FEDERALLY SPONSORED RESEARCH OR DEVELOPMENTNone
PARTIES TO A JOINT RESEARCH AGREEMENTNone
REFERENCE TO A SEQUENCE LISTINGNone
BACKGROUND OF THE INVENTIONTechnical Field of the Invention
The present invention relates generally to database and file management or data structures. Specifically, it provides a system and method for creating global rules that reduce data redundancy and computational latency by consolidating duplicated payor rules.
Description of Related Art
Medical practices treat thousands of patients, insured by various healthcare organizations. As a result, a critical daily component of the Practitioner's organization involves the successful processing and filing of medical claims to a multitude of payors. While there is considerable commonality in claim information between payors, each payor can have differing rules regarding the claim format and content, further increasing the complexity of the processing and filing.
Practice Management Software (PM) is the most common way medical providers submit insurance claims. Many PMs have claim scrubbing features that review claims for inaccuracies prior to submission. However, despite scrubbing efforts to increase successful processing, human error is unavoidable. A common reason for errors is differences between submission requirements among payors. Although some submission requirements apply to all payor organizations (i.e. universal rules), currently used PMs also separately collect and store unique payor rules needed for claim submission compliance. To ensure compliance with all the rules, universal or unique, Practitioners must manually apply the rules for each payor organization—directly reducing available time and resources for seeing patients and earning revenue.
Storing, maintaining, and processing numerous redundant payor rules makes PM software setup very resource intensive. Large amounts of network resources are spent storing and processing superfluous payor rules, thereby causing data clutter. The PM software setup process is further affected due to unnecessary setup protocols that force medical practices to communicate with setup systems. The added inefficiency of data clutter and additional setup protocols cause implementation errors and resource drain, further reducing medical organizations' ability to realize improved data interoperability via collaboration.
The St. Claire, et al. patent application; having U.S. patent application Ser. No. 11/493,922; filed Jul. 27, 2006; and entitled, “System and Method for Health Care Data Integration and Management”; discloses one attempt to eliminate redundant data by focusing on combining duplicate data allocated among distinct medical organizations. The method comprises gathering all data from participating organizations and compiling the data into a conglomerate group. This allows any overlapping data to be identified and permanently eliminated. Then, once the redundant data is removed, the remaining data is re-categorized and disseminated for utilization. However, despite this system and method's efficacy in data reduction among shared communications, the underlying latency issues from resource drain remain unresolved. Eliminating partial data does not address core issues in computational latency. Re-categorizing existing data may reduce clutter, but it has no bearing on expediting automated form completion.
The Kay patent; having U.S. Pat. No. 7,630,911; filed Oct. 23, 2002; and entitled, “Method of Automated Processing of Medical Data for Insurance and Disability Determinations”; discloses another method for the elimination of redundant data during preliminary health insurance vetting methods. The method suggests patients seeking special medical coverage must complete medical claims that declare patients' ailments and/or symptoms. This often results in multiple claims per patient being filed—each claim represents a respective ailment. Medical practitioners must administer specific protocols for each claim, often causing an overlap in the implementation of services. In order to reduce the overlap, the method involves creation of primary databases that encompass explanations for all claim types. An auxiliary database acts as a liaison between the primary database and medical practitioners, providing Practitioners with detailed explanations for non-overlapping administration of services in response to multiple claims. This system does reduce the administration of overlapping medical services, but it perpetuates redundant data computation and introduces additional latency issues inherent in the maintenance of multiple synchronized databases.
The Christen patent; having U.S. Pat. No. 7,970,629; filed Oct. 19, 2007; and entitled, “Adaptive System for Financial Claim Reimbursement Processing”; discloses yet another system attempt to expedite medical claim submissions by reorganizing payor rules to accommodate medical practices' claim submission workflow. In short, medical claims are invoices addressed to insurance payors for compensation for administered medical services and/or goods. Often, distinct payors require unique claim submission compliance, thereby requiring storing and maintaining myriads of data. To alleviate the strain of maintaining copious amounts of data, the system reorganizes the stored rules according to importance and frequency of use with certain claim types. This system addresses the redundant data computation and additional latency issues the prior system discussed, but it does not optimize potential benefits. Simply reallocating payor rules among different data tables produces minimal results because the system still must cipher through myriads of data regardless of relocation.
The Petito at al. patent application; having U.S. patent application Ser. No. 10/664,486; filed Sep. 17, 2003; and entitled, “Automated Work-Flow Management System with Dynamic Interface”; discloses a further system that focuses on eliminating the inputting of redundant data during the automated creation of electronic forms, which are used to communicate among parties despite geographical separation. In this system, users are issued electronic cards (ecards) that are displayed on the input interface and communicate with databases that store algorithms/rules. Ecards provide the system with the data needed for the creation of forms and upon receipt and the algorithms are used to populate the forms. This invention reduces data redundancy; however, it does not reduce the pervasive latency issues caused by excessive data storage. Even though this system does not call for the redundant data to be appended onto the forms, it still requires valuable system resources to be spent housing, processing and managing superfluous data.
The Amar et al. patent; having U.S. Pat. No. 7,617,116; filed Aug. 3, 2001; and entitled, “Practice Management and Billing Automation System”; discloses an additional system that attempts to address problems with PM setup and claim submission protocols. This system's PM setup process includes a setup server that communicates with medical practices and relevant payors. The setup server requests initial setup information such as address, physicians' names, and accepted insurance payors from medical practices. Next, the setup server uses the data provided to begin the PM setup, including retrieving payor rules needed for claim submissions. Insurance payors often require compliance with relative standards during claim submission, thereby requiring subsequent data from medical practices to satisfy compliance. Ideally, the system's setup process would only require a maximum of two data requests; however, unforeseen rules collection issues may easily require additional requests. The likelihood for additional required requests introduces inefficiency into the PM setup process due to excessive communications between parties. Also, this invention's claim submission process lacks efficiency due to inadequate housing and implementation of insurance payor rules. The system creates multiple database tables and each table is utilized specifically to store all rules relating to one payor. Again, even though many rules are commonly shared among payors, the system teaches database storage of duplicate rules, thereby fostering redundancy and computational latency. The system attempts to mitigate this latency by recognizing and partially eliminating redundant rules within individual payor tables that have similar end results. Few redundant rules are actually eliminated though, leaving behind redundant rules related to each payor.
In light of the current state of the art, it is readily apparent that a comprehensive solution to inefficient data processing is needed. Reorganizing, renaming and/or relocating redundant data may provide temporary solutions to part of the problem; however such processes do not optimize database resources that facilitate efficient claim submissions. Thus, there is a need for a system and method of effectively analyzing payor rules to consolidate duplicate rules into new “global” rules, which remove the superfluous data from the database and reduce computational latency.
BRIEF SUMMARY OF THE INVENTIONThe present system and method can be used in health care management data processing systems. Specifically, it can be used in the electronic dissemination of patient records and the writing of insurance policies or the processing of insurance claims. Further uses include the delivery, organization, and computerized arrangement for transfer of critical legal documents.
The invention reduces computational latency caused by storing, maintaining, and administering duplicated data. This latency is most evident in PMs' processing of insurance claims. In order to process claims, PMs require insurance payor rules. Although each payor has proprietary rules, many rules overlap. Without a way to recognize the overlapping rules, the duplicate rules cannot be removed, forcing the PM to cull through duplicate records in the database.
Broadly described, the present invention comprises a Global Rules Engine (GRE) that facilitates latency reduction by analyzing and consolidating redundant rules into Global Rules. In this capacity, the GRE plays a key role in PM setup by electronically collecting practice information needed for PM setup. Previous methods required the same practice information in paper form submission. Due to the vast differences among practices, the accurate and efficient collection of practice data is a critical step. For example, specialized practices often only accept a small subset of insurance payors, while general practices usually accept a much larger number of insurance payors. Hence, the differences among practices directly correlate to distinct PM needs.
Payor-specific rules are unique rules that apply to an individual insurance payor. In order to satisfy claim submission compliance with all of the insurance payors, practices must collect, maintain, and implement myriads of rules per payor. Rather than requiring practices manually gather all mandatory rules, the invention automatically and electronically collects payor data. The system then uses this data to facilitate claim submissions by eliminating redundant rules among payors, automatically reducing computational latency and data clutter. Although the GRE's functionality has no direct bearing on the payor-specific rules themselves, the invention's GRE introduces huge efficiencies in the PMs' ability to retrieve these rules from the database once duplicates have been removed. The efficiencies are also recognized with rules that only apply to two or more payors, but not all. Those rules are also consolidated into Global Rules and applied only to the corresponding payors.
One preferred embodiment uses the GRE to improve claim submissions. The GRE contacts a plurality of insurance payors to collect rules necessary for submission compliance. Upon collecting the rules, the GRE jointly analyzes all rules regardless of payor to identify and eliminate any redundancies. It does this by consolidating duplicate rules into Global Rules, where the duplicate rules comprise the same rule stored in at least two distinct payor data tables. The disclosed system is capable of recognizing all redundant rules despite small differences in syntax. After creating the Global Rules, the system establishes communication with the designated medical practice for the further collection of general information (e.g. physician names and accepted insurance payors). The system then determines which payor/global rules apply and sends them to the corresponding databases. Thus, when processing multiple claims from various payors, the system no longer retrieves identical rules multiple times from different payor data tables.
One example of the invention's utility is apparent when dealing with National Provider Identifier (NPI) numbers used for insurance payor identification. Most insurance payors require mandatory disclosure of NPI numbers in filed claims. Rather than repetitively collecting and storing the same NPI rule from each payor, the invention creates a Global Rule that is applied to all relevant payors, thereby storing the rule only once and reducing superfluous data in the database.
Another embodiment teaches improvements to the PM setup process. Previous systems require extensive communication between setup systems and medical practices. The systems first contact medical practices to collect general information, including accepted insurance payors. Next, the system retrieves payor rules. It is during this retrieval process where the payor rules often disclose additional requirements not satisfied by the initial collection of practice data. The disclosed system precludes subsequent requests by collecting payor rules first, enabling the system to analyze rule nuances. The system creates one primary data request that encompasses all compliance demands, thereby ensuring fulfillment of submission terms. Thus, practices would no longer be faced with frequent data requests that could increase data errors and jeopardize compliance.
One benefit of the invention includes effortless PM setup facilitated by the GRE. Other methods require practices to submit paper forms for setup, which often prolongs setup completion. Still other electronic setup systems require superfluous communication between parties. The present invention enables electronic PM setup, drastically reducing required party communication.
Yet another benefit of the invention includes automated completion of claim forms. Most medical professional providers prefer to submit claims directly to payors electronically. As mentioned, the GRE provides for a quick and easy practice setup process. Because the practice management information is all collected at setup, the system is able to populate claim forms with this information and the information collected via the Global Rules. This allows practitioners to only input claim data once, thereby streamlining the submission processes. By using Global Rules to streamline this process, database resources are more efficiently utilized.
The primary goal of the invention is to remove latency during claim submissions by correcting computational, storage and network inefficiencies. The secondary goal is to improve PM setup by obviating paper form submissions and reducing party communications. The tertiary goal is to reduce claim errors and subsequent claim rejections by automating the claim submission process.
To those skilled in the art, alternate embodiments are appropriate anywhere improvements in efficiencies and accuracy can be achieved by identifying duplicate information and condensing entries—thereby reducing not only setup times, but information processing and overhead, data search latency, document production, etc. For example, other industries where insurance is utilized can easily benefit from the present disclosure. Additionally tax preparation and finance often suffer from excessive amounts of duplicate information, processing and overhead. Technical support in many industries often following common linear trouble-shooting processes, and thus are highly sensitive to inefficiencies in data redundancy and latency. Another possible embodiment is contract administration for any industry, whereby contracts are populated from alternate data sources and the populated entries can become stored data for later maintenance, reducing the requirement to re-enter, or otherwise hand-code free text fields. Ultimately, the efficiencies and accuracy the present disclosure seeks to achieve are useful in many industries and applications besides health care practice management.
These and other features of the present disclosure will become more apparent to one skilled in the art from the following Summary, Brief Description of the Drawings, Detailed Description, and Claims when read in light of the accompanying Detailed Drawings.
The present invention will be better understood by reading the Detailed Description of the Preferred and Selected Alternate Embodiments with reference to the accompanying drawing figures, which are not necessarily drawn to scale, and in which like reference numerals denote similar structure and refer to like elements throughout, and in which:
It is to be noted that the drawings presented are intended solely for the purpose of illustration and that they are, therefore, neither desired nor intended to limit the disclosure to any or all of the exact details of the construction shown, except insofar as they may be deemed essential to the claimed disclosure.
DETAILED DESCRIPTION OF THE PREFERRED AND SELECTED ALTERNATE EMBODIMENTS OF THE INVENTIONIn describing the preferred and selected alternate exemplary embodiments of the present disclosure, as illustrated in
Referring now to
It will be recognized by those skilled in the art that a secure network computing environment 110 may be a LAN, WAN, VPN, cloud, combination thereof or any network configuration of electronic devices. It will further be recognized that global rules engine 102, practice management system 106, and payor systems 108 may function on separate computers (best shown in
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At step 312 (jointly referencing
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The foregoing description and drawings comprise illustrative, exemplary embodiments of the present disclosure. Having thus described exemplary embodiments of the present disclosure, it should be noted by those skilled in the art that the within disclosures are exemplary only, and that various other alternatives, adaptations, and modifications may be made within the scope of the present disclosure. Merely listing or numbering the steps of a method in a certain order does not constitute any limitation on the order of the steps of that method. Likewise, merely listing several alternate embodiments does not constitute any limitation on the other possible embodiments of the present disclosure. Terminologies and specific information sought at certain exemplary steps are not intended to limit the process, but instead show one of multiple possible examples that the typical and exemplary embodiments may resemble.
Many modifications and other embodiments of the disclosure will come to mind to one skilled in the art to which this disclosure pertains having the benefit of the teachings presented in the foregoing descriptions and the associated drawings. Although specific terms may be employed herein, they are used in a generic and descriptive sense only and not for purposes of limitation. Accordingly, the present disclosure is not limited to the specific embodiments illustrated herewith, but is limited only by the following claims.
Claims
1. A system for identifying and condensing analogous information requests and responses comprising:
- a plurality of healthcare claim reimbursement submission systems connected to a public network;
- a group of devices, each of said group of devices having private connections to other said group of devices on said public network comprising:
- a first computing device having a first processor and a first data store, said first processor configured to process a healthcare claim reimbursement request and an electronic remittance advice and said first data store having installed a healthcare practice management system configured to submit a healthcare claim reimbursement request to said plurality of healthcare claim reimbursement submission systems via said public network and configured to receive said electronic remittance advice from said plurality of healthcare claim reimbursement submission systems;
- a second computing device having a second processor and a second data store, said second data store having installed a global rules engine, said global rules engine configured to request and receive an individual payor rule from said plurality of healthcare claim reimbursement submission systems via said public network and configured to request information and receive responses from other computing devices on said public network, wherein said second processor identifies analogous payor rules and identifies analogous information responses to reduce in number said information requests to complete a healthcare claim for reimbursement;
- a third computing device having a third processor, a third data store and a display, wherein said third computing device is securely connected to said first computing device over said public network via a first secure point-to-point connection, connected to said healthcare practice management system, and configured to receive information requests from said second computing device over said public network via a second secure point-to-point connection, having an interface to display said information requests, wherein said third computing device configured to enable a user to provide a response to said information requests and transmit said response to said second computing device via said second secure point-to-point connection.
2. The system of claim 1, wherein said global rules engine installed on said second data store is configured to analyze and compare at least two individual payor rules from said plurality of healthcare claim reimbursement submission systems and identify commonalties among said at least two individual payor rules.
3. The system of claim 2, wherein said global rules engine is further configured to eliminate redundant commonalties among said at least two individual payor rules and thereby configured to create a global rule on said second data store.
4. The system of claim 3, wherein said global rules engine is further configured to associate differences between said at least two individual payor rules with said global rule.
5. The system of claim 4, wherein said global rules engine is configured to reorganize said at least two individual payor rules stored on said second data store according to importance and frequency of use.
6. The system of claim 1, wherein said first computing device is configured to request and receive a plurality of payor rules from a specific set of at least two healthcare claim reimbursement submission systems.
7. The system of claim 6, wherein said global rules engine installed on said second data store is configured to analyze and compare all individual payor rules among said plurality of payor rules stored on said first data store on said first computing device and identify commonalties among said plurality of payor rules.
8. The system of claim 7, wherein said global rules engine is further configured to eliminate redundant commonalties among said plurality of payor rules and thereby configured to create a global rule stored on said first data store.
9. The system of claim 8, wherein said global rules engine is further configured to analyze compare said plurality of rules with said global rule to identify differences among said plurality of rules and said global rule.
10. A system of claim 9, wherein said global rules engine on said second computing device is configured to request said processor on said first computing device to reorganize said at least two individual payor rules stored on said second data store according to importance and frequency of use via said private connection to said first computing device.
11. A method for identifying and condensing analogous information requests and user responses during a setup and maintenance of a healthcare practice management system capable of directly submitting reimbursement claims to a payor via a computer apparatus connected to at least one payor system via a healthcare claim submission system whereby reimbursement information is related to at least one medical treatment of at least one individual, the method comprising the steps of:
- establishing a private connection among a first computing device having a first processor and a first data store and a second computing device having a second processor and a second data store having a global rules engine installed thereon, thereby creating a secure private network;
- establishing a secure point-to-point connection to said secure private network from a third computing device having a third processor, a third data store, and a display via a public network;
- said third computing device, via said secure point-to-point connection, establishing a medical practice management system on said first computing device configured for submission of healthcare claim reimbursements;
- said first computing device, via said secure private network, requesting said second computing device to transmit a first information request having at least a general medical practice information set, a non-payor related information set, and a payor list from said third computing device via said secure point-to-point connection;
- said third computing device, transmitting a first response to said first information request via said secure point-to-point connection to said second computing device;
- storing said first response on said second data store; and
- assembling a global rule thereon said second data store by identifying analogous payor rules corresponding with said payor list, identifying analogous information responses and eliminating any redundancies among analogous payor rules and analogous information responses to reduce the data required to complete said setup and management of said healthcare practice management system.
12. The method of claim 11, further comprising the step of said global rules engine on said second computing device, identifying missing information required to complete information corresponding to said payor list, a set of corresponding payor rules stored on said second data store and said first response, thereby generating a missing information request.
13. The method of claim 12, further comprising the step of said first computing device, requesting said second computing device to transmit said missing information request to said third computing device.
14. The method of claim 13, further comprising the step of said third computing device, transmitting a second response to said third computing device in response to said missing information request.
15. The method of claim 14, further comprising the step of said second computing device, storing said second response on said second data store.
16. The method of claim 15, further comprising the step of said second computing device, updating said global rule thereon said second data store.
17. The method of claim 16, further comprising the step of said global rules engine, analyzing said global rule thereon said second data store for analogous rules and information to further consolidate said payor rules stored within said global rule.
18. The method of claim 17, further comprising the step of said third computing device, causing a change to a general medical practice information set, said non-payor related information set, and said payor list, thereby requiring said second computing device to update said global rule of at least one of a group stored on said first or second computing device on said private network.
19. The method of claim 17, further comprising the step of said third computing device, assembling a healthcare claim for reimbursement via said secure point-to-point connection with said private network and said healthcare practice management system on said first computing device, wherein said first computing device communicates with said global rules engine on said second computing device to reduce information requests required to complete said healthcare claim for reimbursement.
20. The method of claim 19, comprising the step of said first computing device, transmitting and receiving information over a secure network connection to a plurality of healthcare claim submission systems via said public network, said information comprising an electronic remittance advice and a healthcare claim reimbursement request.
Type: Application
Filed: Dec 5, 2016
Publication Date: Mar 23, 2017
Applicant: Nuesoft Technologies, Inc. (Marietta, GA)
Inventors: Massoud Alibakhsh (Atlanta, GA), Shahram Famorzadeh (Marietta, GA)
Application Number: 15/369,589