CA1285070C - Insurance administration system - Google Patents
Insurance administration systemInfo
- Publication number
- CA1285070C CA1285070C CA000570175A CA570175A CA1285070C CA 1285070 C CA1285070 C CA 1285070C CA 000570175 A CA000570175 A CA 000570175A CA 570175 A CA570175 A CA 570175A CA 1285070 C CA1285070 C CA 1285070C
- Authority
- CA
- Canada
- Prior art keywords
- benefits
- computer system
- patient
- data
- sponsor
- Prior art date
- Legal status (The legal status 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 status listed.)
- Expired - Lifetime
Links
Classifications
-
- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
- G06Q40/02—Banking, e.g. interest calculation or account maintenance
-
- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
- G06Q40/08—Insurance
-
- 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
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
Abstract
ABSTRACT OF THE DISCLOSURE
The computerized insurance claim processing system links the physician's office and the provider of insurance coverage by means of a central administration computer. The system provides up-to-date information to the provider of health care services as to insurance coverage of a patient. The system also allows real time modification of the information, including the identity of patients covered and the type of insurance benefits.
The computerized insurance claim processing system links the physician's office and the provider of insurance coverage by means of a central administration computer. The system provides up-to-date information to the provider of health care services as to insurance coverage of a patient. The system also allows real time modification of the information, including the identity of patients covered and the type of insurance benefits.
Description
INSURANCE ADMINISTRATION SYSTEM
Th~ invention relates to computerized systems for processing insurance claims.
BACKGROUND OF THE INVENTION
A type of processing system for medical insurance claims is discussed in U.S. Patent No. 4,491,725, issued to Pritchard, on January 1, 1985. The patent discusses a system in which a patient seeking medical treatment presents an identification card at a physician's office. Coded data is electronically read from the card, and transmitted to a central brokerage computer. The brokerage computer ascertains from a data base whether the patient is covered by an insurance policy, and, if so, whether the policy will fully pay for the medical treatment sought by the patient. The brokerage computer informs the physician immediately of the information found~ The patent further discusses various types of funds transfer which can occur as payment for the medical treatment.
However, this patent does not appear to address the question of (1) How the information contained in the data base is derived, and (2) How and when the information in the data base is updated. The latter question can significantly affect the cost incurred by an employer in providing a group medical insurance plan for its employees. For example, the data base contains a roster of insured employees which must be updated as employees leave the employing company. However, because of various delays, some rosters are updated only once per month. This ycc/sp 7~3 monthly updating has the result that an employee leaving the service of a company nevertheless retains the ability, whether intended or not, to obtain treatment under the medical insurance coverage until his name is re~oved from the roster If a month is assumed to contain thirty days, then, on average, every employee who leaves the employment of a company retains insurance coverage for fifteen days afterward, at the employer's expense.
In addition, there is another possible soui$e of expense to employers based on departing employees. The Consolidated Omnibus Budget Reconcillation Act of 1985 (COBRA) (P.L. 99-2721 requires that, under certain circumstances, an employer must continue an employee's insurance coverage after terminating employment.
Both the occurrence of late roster ~pdating, together with the existence of COBRA, create complications when a former employee seeks medical care, because they create uncertainty as to the insurance coverage of the employee. It is very important that the -treating physician know whether the employee has insurance benefits.
OBJECT OF THE INVENTION
It is an object of the invention to provide an improved system for the administration of medical insurance claims.
SUMMARY OF TIE INVENTION
In one form of the inventionr a third party maintains a data base in an administration computer. The data base includes a comprehensive roster of all persons having insurance ~enefits under a given insurance plan, as ~ell as'the types of benefits available, including the particular medical treatments which are reimbursible by insurance, and the dollar value of ~he reimbursement for each treatment. A treating physician has communication equipment which can communicate in real time with the administration computer in order to ascertain whether a given patient is on the roster of covered individuals for a given insurance plan, and whether a proposed treatment is reimbursible, as well as -the amount of reimbursement. If the data base indicates that the proposed treatment is in fact covered, the physician can request that the amount of reimbursement be immediately credited to him, as by a funds transfer to his bank.
An employer, who provides the insurance coverage for the benefit of an employee-patient, also has communication equipment which can link to the administration computer, but in a different manner than that of the physician: the employer can modify, in reaI time, the da-ta base. For example, an employer can acld and delete persons to the roster of those insured, as people enter and leave his employment. E~rther, the employer can change the benefits which the plan provides. For example, he may change the reimbursement amount for treatment of a sprained wrist from X
dollars to Y dollars.
Further, the employer can audit the activity of his insurance plan as reported by the data base. Eor example, he can track, by addres-sing the data base, the insurance claim activity of each insured individual.
BRIEF DESCRIPTION OF ~ E DRAWINGS
Fiqure 1 illustrates a simplified overview of the system.
rlgures 2-5 illustrate a flow chart which describes the operation of parts of ~ne sy,stem of Figure 1.
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Th~ invention relates to computerized systems for processing insurance claims.
BACKGROUND OF THE INVENTION
A type of processing system for medical insurance claims is discussed in U.S. Patent No. 4,491,725, issued to Pritchard, on January 1, 1985. The patent discusses a system in which a patient seeking medical treatment presents an identification card at a physician's office. Coded data is electronically read from the card, and transmitted to a central brokerage computer. The brokerage computer ascertains from a data base whether the patient is covered by an insurance policy, and, if so, whether the policy will fully pay for the medical treatment sought by the patient. The brokerage computer informs the physician immediately of the information found~ The patent further discusses various types of funds transfer which can occur as payment for the medical treatment.
However, this patent does not appear to address the question of (1) How the information contained in the data base is derived, and (2) How and when the information in the data base is updated. The latter question can significantly affect the cost incurred by an employer in providing a group medical insurance plan for its employees. For example, the data base contains a roster of insured employees which must be updated as employees leave the employing company. However, because of various delays, some rosters are updated only once per month. This ycc/sp 7~3 monthly updating has the result that an employee leaving the service of a company nevertheless retains the ability, whether intended or not, to obtain treatment under the medical insurance coverage until his name is re~oved from the roster If a month is assumed to contain thirty days, then, on average, every employee who leaves the employment of a company retains insurance coverage for fifteen days afterward, at the employer's expense.
In addition, there is another possible soui$e of expense to employers based on departing employees. The Consolidated Omnibus Budget Reconcillation Act of 1985 (COBRA) (P.L. 99-2721 requires that, under certain circumstances, an employer must continue an employee's insurance coverage after terminating employment.
Both the occurrence of late roster ~pdating, together with the existence of COBRA, create complications when a former employee seeks medical care, because they create uncertainty as to the insurance coverage of the employee. It is very important that the -treating physician know whether the employee has insurance benefits.
OBJECT OF THE INVENTION
It is an object of the invention to provide an improved system for the administration of medical insurance claims.
SUMMARY OF TIE INVENTION
In one form of the inventionr a third party maintains a data base in an administration computer. The data base includes a comprehensive roster of all persons having insurance ~enefits under a given insurance plan, as ~ell as'the types of benefits available, including the particular medical treatments which are reimbursible by insurance, and the dollar value of ~he reimbursement for each treatment. A treating physician has communication equipment which can communicate in real time with the administration computer in order to ascertain whether a given patient is on the roster of covered individuals for a given insurance plan, and whether a proposed treatment is reimbursible, as well as -the amount of reimbursement. If the data base indicates that the proposed treatment is in fact covered, the physician can request that the amount of reimbursement be immediately credited to him, as by a funds transfer to his bank.
An employer, who provides the insurance coverage for the benefit of an employee-patient, also has communication equipment which can link to the administration computer, but in a different manner than that of the physician: the employer can modify, in reaI time, the da-ta base. For example, an employer can acld and delete persons to the roster of those insured, as people enter and leave his employment. E~rther, the employer can change the benefits which the plan provides. For example, he may change the reimbursement amount for treatment of a sprained wrist from X
dollars to Y dollars.
Further, the employer can audit the activity of his insurance plan as reported by the data base. Eor example, he can track, by addres-sing the data base, the insurance claim activity of each insured individual.
BRIEF DESCRIPTION OF ~ E DRAWINGS
Fiqure 1 illustrates a simplified overview of the system.
rlgures 2-5 illustrate a flow chart which describes the operation of parts of ~ne sy,stem of Figure 1.
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ET _LED DESCRIPTION OF THE INVENTION
Figure 1 depicts a simplified overview of one form of the inven-tion. An administration computer 3 maintains a data base for each insurance plan provided by an employer. File 6 indicates the data base for plan ABC maintained by employer Alpha Company. The file includes a roster of all insur~d employees of Alpha Company, their spouses and dependents. In addition, the file includes a list of all medical treatments for which insurance COmpensatiQn is available. (Each treat-ment is typically called a diagnosis, because the physician usually undertakes a diagnosis prior to embarkiny upon the treatment which the diagnosis indicates~ An example would be a diagnosis of a sprained wrist in a patient Adam, followed by the treatment considered proper under the circumstances.) The flle also contains a list of dollar amounts payable for each type of dia~nosis. For example, in the file, X dollars is associated with the diagnosis for sprained wrist, meaning that insurance plan ABC will pay X dollars for the treatment of a sprained wrist.
When a patient 9 visit3 a physician for treatment of the sprained wrist, the patient 9 presents an identification card 15 as evidence that the patient is covered by insurance plan ABC. The physician, using data ter~inal 18, communicates with the administration computer 3 on data link 21, and states to the computer the identity of the patient (Adam), the name of the patient's plan (A~C in this case) together with the diagnosis (sprained wrist). A computer 3 locates the file corresponding to plan ABC, confirms that the patient Adam is on the roster of insured persons, confirms whether the plan ABC will pay the physician for the given diagnosis (sprained wrist) and states the amount of reimbursement. In responsej the physician can request the computer 3 to arrange a trans~er of funds as payment.
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If the amount of reimbursement is less than the normal charge made by the physician, a balance would exist. The physician then gives the patient an option of charging the balance to the patient's credit card. If the patient wishes to do so, the patient provides a suitable credit card number, which is communicated to the computer 3, which appropriately charges the patient's credit card account.
In addition, the computer stores the diagnosis and the amount paid to the physlcian, together with other relevant data, in a separate file associated with the patient's name. Thus, the file for plan A~C is updated at the time of treatment, and, further, the physician's office itself does the updating, although in an indirect manner.
The employer which provides insurance coverage to patien-t 9 also has access to the administratlon computer 3 along data link 24. ~owever, the employer has access to a wider range of data in the file for the A~C
plan than does the physician. As stated above, the physician only has access to data indicating whether or not a particular diagnosis is covered, the amount of reimbursement, and other similar data. In con-txast, the employer has access to all data contained within the file for the ABC plan. Further, the employer can modify the data ln the file.
For example, the employer can add and delete the names of insured persons as appropriate. Still further, the employer can change the benefits provided by the plan ABC as needed. For example, the employer can change the types of diagnoses for which reimbursement will be allowed. The employer may decide that elective cosmetic facial surgery, as distinct from restorative facial surgery used to xestore damage caused by an accident, should not be a cost borne by pian ABC, but should be paid by the patient. In such a case, the employer would change the file to so indicate.
r The employer can also change the dollar amount of reimbursement for a given dlagnos~s. For example, the employer may change the dollars reimbursements for a sprained wrist from X dollars to Y dollars.
In addition, the employer Alpha can audit the operation of his own plan ABCo For example, the roster of insured persons is available to him, so that he knows informat~on as to the eligibility of his employees for insurance benefits. Also, as mentioned above, the computer 3 stores the diagnosis and treatment information as they occur. This allows the employer to retrieve such information and to evaluate the insurance claim activity of his employees. The employer can also make detailed sta-tisti-cal analyses of claim activity and plan expenditures by using the data available. Figures 2-5 contain a flow chart describing in more detail the operation of the system of Figure 1 and will now be considered.
Block 30 in Figure 2 indicates that a card holder (i.e., a patient) brings his card (the card 15 in Figure 1) to a provider site.
"Provider site" is a term in the art used to refer to one who provides medical services, namely, a physician or hospital~ Block 33 indicates that the card is read by an "8610". "8610" is shorthand notation for a ~ra C~ q~
Datatrol 8610~ computer t rminal and associated printer indicated by numeral 18 in Figure 1. This equipment is available from Datatrol Corporation, located in Minnetonka, Minnesota. Block 33 indicates that if the card is not readable, then an operator at the provider site types in the client's identification symbol, namely, his social security number (SSN), and a client code, which is a number identifying the ABC plan, ~om ~hlch lnsuxance aove~a~e i~ ~ough~, Block 3~ catés ~hat ~he pa~ièn~is ~1à4~ o~ bir~h i ~Bi ~nd relationship to the card holder is keyed into the terminal. In this example, the relationship is "employee", because Adam himself is seeking treatment. Were his wife to do so, the relationship would be "spouse".
. ~ ~2~070 Blocks 33 and 36 pro~ide identification of the pa~ient in order to assure that only the actual patient whose name is on the plan's roster receives medical treatment, and that no imposters do.
Block 39 refers to statement of a reason for the visit to the physician selected from a tablev One type of table includes four reas-ons, namely, the reasons of illness, prevention, maternity or accident.
The reason ~or the visit can be important for insurance purposes because different insurance coverage may be available for different reasons motivating a visit. For example, plan ABC may provide maternity benefits for Adam'~ wife, but not hls daughter. Further, some reasons, such as accident, can cause legal rights to arise for the benefit of in the plan, and so special procedures should be taken. For example, the YES (Y) path leading from block 42 indicates that an accident motivated the visit to the physician's office. Block 45 indicates that the computer terminal prompts the patient to complete a subrogation form which can give certain subrogation rights to the plan ABC. For example, an automobile accident rnay have causçd the condition, so that an automobile insurance company may have a liability to the patient or to Plan ABC~
Block 48 indicates that the patient states whether he has pre-v~ously keen treated for the present condition. As block 51 indicates, another insurance plan may be liable to the patient for the condition.
For example, a wife may be employed and have insurance benefits making the husband's plan primarily liable, meaning that the patient and the wife's plan are only liable after the husband's plan pays. Block 54 indicates that the identity of the provider is selected (i.e., the physician) from a table of codes.
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The inventors point out that7 up to block 54 in Figure 2A, no communication with the administration computer has yet been undertaken.
However, at block 57, the local terminal 18 in the physician's office communicates data via a local telephone call to the adminis-~ration (i.e., host) computer 3u Blocks 63, 66 and 68 indicate that block 71 is reached if the data base for plan A~C indicates that (1) the proper social security number, (2) proper provider, (3) proper date of birth and (4) proper relationship have been given by the patient. If not, circles 3A
and 3B are reached, as will be later discussed.
Restated, reaching block 71 indicates that the patient is not an imposter. Now it must be ascertained whether the person has insurance coverage. Block 71 indicates that the administration computer searches the roster to determine this. If the patie~t is fo~d on the roster, then block 73 is reached. (The other situations indicated in block 71 will be discussed later.) Block 73 refers to a search ~y the administra-tion computer of the data base of plan ABC to ascertain whether the reason for the visit in block 39 in Figure 2 i5 covered (i.e., reimbur-sible) by plan ABC. In addition, thought not indicated in Figure 2B, block 73 can determine at this time whether ~he diagnosis (i.e., sprained wrist) is cover~3d.
~ f the visit is covered, block 76 refers to the assi~nment of an authorization code for the transaction (i.e., treatment). An authoriza-tion code is a unique symbol, which identifies the transaction in an unmistakable manner as eligible for treatment. The authorization code functions to facilitate bookkeeping, much in the way that a serial number on an invoice for other purchases does so.
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Block 79 refers to the creation of an eligibility record in the ad~inistration computer. This refers to an allocation of memory space, having the authorization code as an address, in anticipation of data which will later be received from the physician, after treatment has been completed~ Block 82 mdicates that the eligibility record is transmitted to the physician's terminalO This means ~hat an indication that the patient is in fact on the plan's roster, together with an affirmation that the reason for the visit is covered, is transmitted. One type of message indicating eligibility would be "eligibility approved". In addition, the authorization code assigned in block 76 is transmitted.
The blocks in Figure 26 following block 82 relate to error handling and are considered self-explanatory. The block labeled "terminate" indicates that the telephone connection is terminated.
A-t this time a physician has information indicating that treat-ment of the diagnosed condition is covered by insurance. Following treatment, the physician, as indicated by block 85 in Figure 3, enters authorization code into his local terminal in Figure 1. Blocks 88 and 91 indicate that the local tenminal searches and finds the patient's name, Adam, so that the treatment portion of the transac-tion can be completed and transmitted to the administration computer.
Block 95 indicates that the physician enters a code identifying the diagnosis (sprained wrist~. Block 97 indicates that the physician enters up -to ten "procedure codes", which refer to the treatments for a sprained wrist selected by the physician. Blocks 101 and 104 indicate that the diagnosis and procedure codes are now transmitted via a local telephone call to the administration computer 3. Block 106 indicates that a check is made to verify that the codes received are actua~ly existing, and not fictitious, codes. Block 109 indicates that the administration computer searches the data base for plan ABC and _ g `calculates the reimbursement specified by the employer for each treatment. Block 112 indicates that these reimbursements are under the employer's control, and will be discussed later in more detail. Block 115 ascertains whether the present diagnosis (sprained wrist) is covered by plan ABC, whether the given treatments (e.g., anaesthetics applied, immobilization by a plaster cast) are covered, the dollar amounts o the coverage, and whether a deductible amount or a co-payment apply. As indicated by blocks 11~ and 121, data regarding the net payment which the plan ABC will reimburse the physician is transmitted to the physician's terminal. A printer 130 prints the relevant data on a receipt 131, as indicated by block 125. The patient signs the receipt as acknowledgement that tr2atment was done. Block 13S indicates that the da-ta link between the physician's terminal and the administration computer is then terminated.
At this point, the patient's identity has been veriied, as well as his coverage under plan ABC (i.e., his eligibility). Also, the diagnosis and treatments have been transmitted to the administration computer, wherein they are stored for future use, and the administration computer has transmitted to the physician's terminal the reimbursement amounts for the treatments involved. It is possible that the reimburse-ment amounts are less than the physician's customary charges for the treatments that the patient owes a deductible, or that the computer 3 found the patient or the treatments to be non-insured, with the result that a balance of payment remains. Figure 4 describes an option under which the patient can charge the balance to a credit card. The YES path from block 140 indicates that the charges are to be placed upon a credit card account. Block 140 indicates that the necessary information is either electronically read ("swlped"), or directly typed into the ph~sician's termin'al, together with the dollar amount. At this time, the 5q~
data link is established between the physician's terminal and the administration computer. Block 144 indicates that the administration computer verifies with the bank issuing the credit card has stated that ~he balance amount can be properly applied to the credit card account. If so, block 146 is reached, wherein the necessary information is printed by printer 130 in Figure 1 upon a receipt 131, and the data link i5 terminated by block 148~
Figure 5 indicates one proced~re for providing plan payment to the physician. The inquiry of block 150 refers to the authorization discussed in connection with block 76 in Figure 2B, wherein the authorization code was established and stored. If payment was authorized, block 152 is reached, which indicates that a check is drawn on the client's bank account and mailed to the provider. mis means that the administration computer prints a ~ank ch~ck drawing upon a bank account ~hich is funded by plan A~C, or by the insurance company itself, and mailed to the provider, that is, to the physician.
Block 155 indicates that the administration computer maintains a record of checks printed in block 152. The record is available to the employer and ~he insurance co~pany through data link 24 in Figure 1.
Further discussion of systems which accomplish the funds transfer described in Fi~ures 4 and 5 is found in U.S. Patent No. 4,346,442, Musmanno, 1982.
If block 150 indicates that no payment was authorized, then block 157 indicates that a message, indicating that payment is not authorized, is sent to the physician's terminal.
The preceding discussion has been chiefly concerned with aspects of verification. That is, verification of the patient's identity was undertaken, verification that the diagnoses and treatment were of the type which a given plan (ABC) would reimburse, and verification or ascertainment of the dollar amounts reimbursible for - each treatment.
ycc/sp 11 37~
~However, in some circumstances, a system of notification and tracking of former employees n~y be desirable~ as discussed above, in order ~o comply with contractural or statuatory re~ulrements. One such system will now be described in connection with the following Table 1. Table 1 outlines a sequence of steps taken by, and in connection with, the administration computer.
TABLE I
1. Delete Adams, spouse, and dependents from roster of insured persorJs.
2. Notify Adams and perhaps others of the terminatioa of insurance covexage. Notify them that they have the option within X days to continue certain insurance benefits at stated premium rates. Send these notices by certified mail.
3. If notified persons respond within predetermined time, indicating desire to purchase insurance, print and send a package of payment coupons for making periodic payments.
ET _LED DESCRIPTION OF THE INVENTION
Figure 1 depicts a simplified overview of one form of the inven-tion. An administration computer 3 maintains a data base for each insurance plan provided by an employer. File 6 indicates the data base for plan ABC maintained by employer Alpha Company. The file includes a roster of all insur~d employees of Alpha Company, their spouses and dependents. In addition, the file includes a list of all medical treatments for which insurance COmpensatiQn is available. (Each treat-ment is typically called a diagnosis, because the physician usually undertakes a diagnosis prior to embarkiny upon the treatment which the diagnosis indicates~ An example would be a diagnosis of a sprained wrist in a patient Adam, followed by the treatment considered proper under the circumstances.) The flle also contains a list of dollar amounts payable for each type of dia~nosis. For example, in the file, X dollars is associated with the diagnosis for sprained wrist, meaning that insurance plan ABC will pay X dollars for the treatment of a sprained wrist.
When a patient 9 visit3 a physician for treatment of the sprained wrist, the patient 9 presents an identification card 15 as evidence that the patient is covered by insurance plan ABC. The physician, using data ter~inal 18, communicates with the administration computer 3 on data link 21, and states to the computer the identity of the patient (Adam), the name of the patient's plan (A~C in this case) together with the diagnosis (sprained wrist). A computer 3 locates the file corresponding to plan ABC, confirms that the patient Adam is on the roster of insured persons, confirms whether the plan ABC will pay the physician for the given diagnosis (sprained wrist) and states the amount of reimbursement. In responsej the physician can request the computer 3 to arrange a trans~er of funds as payment.
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If the amount of reimbursement is less than the normal charge made by the physician, a balance would exist. The physician then gives the patient an option of charging the balance to the patient's credit card. If the patient wishes to do so, the patient provides a suitable credit card number, which is communicated to the computer 3, which appropriately charges the patient's credit card account.
In addition, the computer stores the diagnosis and the amount paid to the physlcian, together with other relevant data, in a separate file associated with the patient's name. Thus, the file for plan A~C is updated at the time of treatment, and, further, the physician's office itself does the updating, although in an indirect manner.
The employer which provides insurance coverage to patien-t 9 also has access to the administratlon computer 3 along data link 24. ~owever, the employer has access to a wider range of data in the file for the A~C
plan than does the physician. As stated above, the physician only has access to data indicating whether or not a particular diagnosis is covered, the amount of reimbursement, and other similar data. In con-txast, the employer has access to all data contained within the file for the ABC plan. Further, the employer can modify the data ln the file.
For example, the employer can add and delete the names of insured persons as appropriate. Still further, the employer can change the benefits provided by the plan ABC as needed. For example, the employer can change the types of diagnoses for which reimbursement will be allowed. The employer may decide that elective cosmetic facial surgery, as distinct from restorative facial surgery used to xestore damage caused by an accident, should not be a cost borne by pian ABC, but should be paid by the patient. In such a case, the employer would change the file to so indicate.
r The employer can also change the dollar amount of reimbursement for a given dlagnos~s. For example, the employer may change the dollars reimbursements for a sprained wrist from X dollars to Y dollars.
In addition, the employer Alpha can audit the operation of his own plan ABCo For example, the roster of insured persons is available to him, so that he knows informat~on as to the eligibility of his employees for insurance benefits. Also, as mentioned above, the computer 3 stores the diagnosis and treatment information as they occur. This allows the employer to retrieve such information and to evaluate the insurance claim activity of his employees. The employer can also make detailed sta-tisti-cal analyses of claim activity and plan expenditures by using the data available. Figures 2-5 contain a flow chart describing in more detail the operation of the system of Figure 1 and will now be considered.
Block 30 in Figure 2 indicates that a card holder (i.e., a patient) brings his card (the card 15 in Figure 1) to a provider site.
"Provider site" is a term in the art used to refer to one who provides medical services, namely, a physician or hospital~ Block 33 indicates that the card is read by an "8610". "8610" is shorthand notation for a ~ra C~ q~
Datatrol 8610~ computer t rminal and associated printer indicated by numeral 18 in Figure 1. This equipment is available from Datatrol Corporation, located in Minnetonka, Minnesota. Block 33 indicates that if the card is not readable, then an operator at the provider site types in the client's identification symbol, namely, his social security number (SSN), and a client code, which is a number identifying the ABC plan, ~om ~hlch lnsuxance aove~a~e i~ ~ough~, Block 3~ catés ~hat ~he pa~ièn~is ~1à4~ o~ bir~h i ~Bi ~nd relationship to the card holder is keyed into the terminal. In this example, the relationship is "employee", because Adam himself is seeking treatment. Were his wife to do so, the relationship would be "spouse".
. ~ ~2~070 Blocks 33 and 36 pro~ide identification of the pa~ient in order to assure that only the actual patient whose name is on the plan's roster receives medical treatment, and that no imposters do.
Block 39 refers to statement of a reason for the visit to the physician selected from a tablev One type of table includes four reas-ons, namely, the reasons of illness, prevention, maternity or accident.
The reason ~or the visit can be important for insurance purposes because different insurance coverage may be available for different reasons motivating a visit. For example, plan ABC may provide maternity benefits for Adam'~ wife, but not hls daughter. Further, some reasons, such as accident, can cause legal rights to arise for the benefit of in the plan, and so special procedures should be taken. For example, the YES (Y) path leading from block 42 indicates that an accident motivated the visit to the physician's office. Block 45 indicates that the computer terminal prompts the patient to complete a subrogation form which can give certain subrogation rights to the plan ABC. For example, an automobile accident rnay have causçd the condition, so that an automobile insurance company may have a liability to the patient or to Plan ABC~
Block 48 indicates that the patient states whether he has pre-v~ously keen treated for the present condition. As block 51 indicates, another insurance plan may be liable to the patient for the condition.
For example, a wife may be employed and have insurance benefits making the husband's plan primarily liable, meaning that the patient and the wife's plan are only liable after the husband's plan pays. Block 54 indicates that the identity of the provider is selected (i.e., the physician) from a table of codes.
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The inventors point out that7 up to block 54 in Figure 2A, no communication with the administration computer has yet been undertaken.
However, at block 57, the local terminal 18 in the physician's office communicates data via a local telephone call to the adminis-~ration (i.e., host) computer 3u Blocks 63, 66 and 68 indicate that block 71 is reached if the data base for plan A~C indicates that (1) the proper social security number, (2) proper provider, (3) proper date of birth and (4) proper relationship have been given by the patient. If not, circles 3A
and 3B are reached, as will be later discussed.
Restated, reaching block 71 indicates that the patient is not an imposter. Now it must be ascertained whether the person has insurance coverage. Block 71 indicates that the administration computer searches the roster to determine this. If the patie~t is fo~d on the roster, then block 73 is reached. (The other situations indicated in block 71 will be discussed later.) Block 73 refers to a search ~y the administra-tion computer of the data base of plan ABC to ascertain whether the reason for the visit in block 39 in Figure 2 i5 covered (i.e., reimbur-sible) by plan ABC. In addition, thought not indicated in Figure 2B, block 73 can determine at this time whether ~he diagnosis (i.e., sprained wrist) is cover~3d.
~ f the visit is covered, block 76 refers to the assi~nment of an authorization code for the transaction (i.e., treatment). An authoriza-tion code is a unique symbol, which identifies the transaction in an unmistakable manner as eligible for treatment. The authorization code functions to facilitate bookkeeping, much in the way that a serial number on an invoice for other purchases does so.
. ~.
'~;
. , ~ 7 ~ 35~7~
Block 79 refers to the creation of an eligibility record in the ad~inistration computer. This refers to an allocation of memory space, having the authorization code as an address, in anticipation of data which will later be received from the physician, after treatment has been completed~ Block 82 mdicates that the eligibility record is transmitted to the physician's terminalO This means ~hat an indication that the patient is in fact on the plan's roster, together with an affirmation that the reason for the visit is covered, is transmitted. One type of message indicating eligibility would be "eligibility approved". In addition, the authorization code assigned in block 76 is transmitted.
The blocks in Figure 26 following block 82 relate to error handling and are considered self-explanatory. The block labeled "terminate" indicates that the telephone connection is terminated.
A-t this time a physician has information indicating that treat-ment of the diagnosed condition is covered by insurance. Following treatment, the physician, as indicated by block 85 in Figure 3, enters authorization code into his local terminal in Figure 1. Blocks 88 and 91 indicate that the local tenminal searches and finds the patient's name, Adam, so that the treatment portion of the transac-tion can be completed and transmitted to the administration computer.
Block 95 indicates that the physician enters a code identifying the diagnosis (sprained wrist~. Block 97 indicates that the physician enters up -to ten "procedure codes", which refer to the treatments for a sprained wrist selected by the physician. Blocks 101 and 104 indicate that the diagnosis and procedure codes are now transmitted via a local telephone call to the administration computer 3. Block 106 indicates that a check is made to verify that the codes received are actua~ly existing, and not fictitious, codes. Block 109 indicates that the administration computer searches the data base for plan ABC and _ g `calculates the reimbursement specified by the employer for each treatment. Block 112 indicates that these reimbursements are under the employer's control, and will be discussed later in more detail. Block 115 ascertains whether the present diagnosis (sprained wrist) is covered by plan ABC, whether the given treatments (e.g., anaesthetics applied, immobilization by a plaster cast) are covered, the dollar amounts o the coverage, and whether a deductible amount or a co-payment apply. As indicated by blocks 11~ and 121, data regarding the net payment which the plan ABC will reimburse the physician is transmitted to the physician's terminal. A printer 130 prints the relevant data on a receipt 131, as indicated by block 125. The patient signs the receipt as acknowledgement that tr2atment was done. Block 13S indicates that the da-ta link between the physician's terminal and the administration computer is then terminated.
At this point, the patient's identity has been veriied, as well as his coverage under plan ABC (i.e., his eligibility). Also, the diagnosis and treatments have been transmitted to the administration computer, wherein they are stored for future use, and the administration computer has transmitted to the physician's terminal the reimbursement amounts for the treatments involved. It is possible that the reimburse-ment amounts are less than the physician's customary charges for the treatments that the patient owes a deductible, or that the computer 3 found the patient or the treatments to be non-insured, with the result that a balance of payment remains. Figure 4 describes an option under which the patient can charge the balance to a credit card. The YES path from block 140 indicates that the charges are to be placed upon a credit card account. Block 140 indicates that the necessary information is either electronically read ("swlped"), or directly typed into the ph~sician's termin'al, together with the dollar amount. At this time, the 5q~
data link is established between the physician's terminal and the administration computer. Block 144 indicates that the administration computer verifies with the bank issuing the credit card has stated that ~he balance amount can be properly applied to the credit card account. If so, block 146 is reached, wherein the necessary information is printed by printer 130 in Figure 1 upon a receipt 131, and the data link i5 terminated by block 148~
Figure 5 indicates one proced~re for providing plan payment to the physician. The inquiry of block 150 refers to the authorization discussed in connection with block 76 in Figure 2B, wherein the authorization code was established and stored. If payment was authorized, block 152 is reached, which indicates that a check is drawn on the client's bank account and mailed to the provider. mis means that the administration computer prints a ~ank ch~ck drawing upon a bank account ~hich is funded by plan A~C, or by the insurance company itself, and mailed to the provider, that is, to the physician.
Block 155 indicates that the administration computer maintains a record of checks printed in block 152. The record is available to the employer and ~he insurance co~pany through data link 24 in Figure 1.
Further discussion of systems which accomplish the funds transfer described in Fi~ures 4 and 5 is found in U.S. Patent No. 4,346,442, Musmanno, 1982.
If block 150 indicates that no payment was authorized, then block 157 indicates that a message, indicating that payment is not authorized, is sent to the physician's terminal.
The preceding discussion has been chiefly concerned with aspects of verification. That is, verification of the patient's identity was undertaken, verification that the diagnoses and treatment were of the type which a given plan (ABC) would reimburse, and verification or ascertainment of the dollar amounts reimbursible for - each treatment.
ycc/sp 11 37~
~However, in some circumstances, a system of notification and tracking of former employees n~y be desirable~ as discussed above, in order ~o comply with contractural or statuatory re~ulrements. One such system will now be described in connection with the following Table 1. Table 1 outlines a sequence of steps taken by, and in connection with, the administration computer.
TABLE I
1. Delete Adams, spouse, and dependents from roster of insured persorJs.
2. Notify Adams and perhaps others of the terminatioa of insurance covexage. Notify them that they have the option within X days to continue certain insurance benefits at stated premium rates. Send these notices by certified mail.
3. If notified persons respond within predetermined time, indicating desire to purchase insurance, print and send a package of payment coupons for making periodic payments.
4. If participants make no response within the predetermined time, record this fact in the data base for plan ABC.
5. (Optional) If, as in paragraph 4, no response has been received, print and transmit to the former participants ! a second, backup notice.
Line 1 in Table 1 indicates that the Adams ~amily is deleted from the roster of insured persons under the ABC plan, perhaps because of termination of employment. This is done directly by the empioyer or data link 24. One significant consequence of this deletion from the :
~ ~$~ sJ~
~roster is that, should a physician make inquiry using the physician's data link 21, the administration computer has information, almost on an imn~diate basis, allowing the computer to inform the physician that the Adams family i5 no longer covered by the ABC plan. However, in some cases, discussed later, the computer may refrain from stating tha-t the family is not covered by the ABC plan, and instead indicate that the family presently has an mdeterminate status as to coverage.
Upon deletion of the Adams' participants from the plan, and if the employer so requests, either at the time of deletion, or at a prior time, administration computer 3 activates a printer 170 which prints a notice which i5 transmitted to one or more members of the family, notify-ing them of the fact of termination, and offering them the option to purchase within a stated period of time the same or similar insurance which they previously had, at stated premium rates. The letter is transmitted to the Adams family~ and the admhlistration computer then sets into motion a programming routine, known in the art, to track the response of the Adam's family, when it occurs.
If one or more of the family me~bers respond favorably, in writing, an operator enters the proper data into the administration computer. In response, the computer, using printer 170, prints a group of payment coupons, which are mailed to the electing participants. The participants return the coupons with payment, on a periodic basis, and the coupons assist the administration computer in tracking the payment history of the electing participants. The co~pons bear sufficient ! information to do this, and can be machine-readable by the administration computer, as known in the art.
If no response is received in the stated time, the computerr having an internal time clock, as known in the art, notifies the data base for plan ABC, an~ programming steps are taken to change the status 5~
of the Adams family ~rom indeterminate to terminated, as will now be discussed.
As was stated earlier, it may be the case that an option was given to the Adams family to elect to purchase insurance within a stated time period. This option can be given in fulfillment of a collective bargaining agreement, state or federal statutes, as discussed earlier, or for other reasons. Further, the option may have certain retroactive aspects. For example, the employer may be required to give the former employee the right to exercise the option for a stated period of time, such as sixty days. If the option is retroactive, the following sequence of events can occ~r. Termination of emplo~ment can occur on July l. The notice described in ~ine 2 of Table 1 can be sent on the same day, July 1. The notice can be received by the employee on ~uly 2 and the notice can give him sixty days within which to decide whether to purchase insurance. The employee may visit a physician on July lS, but before he exercised the option~ If he exercises the option on July 20, and pays the insurance premium as re~uired, the ABC plan may be required to pay for the July 15 visit to the physician. Therefore, the administration computer, ln searching the data base in response to ~he physician's inquiry on ~uly 15, classifies the Adams family as indeterminate until the option is exercised, or the option expires.
Continuing the example, if the option expires on September 1, without being exercised, and if Adams visits a physician on Septen~er 10, the a~ninistration computer, in response to the physician's inquiry states that Adams is terminated from the ABC plan, and not under indeter-minate status. Further, the classification was made by the computer immediately upon expiration of the option, which was a stated period, (sixty days in this case) after malling of the notice discussed in Line 2 of Table 1.
` Several important aspects of the invention are the following;
1. As Figure 1 indicates, an employer can add and delete beneficiaries, as well as change provisions of a plan, by using data link 24. Further, as the discussion above indicates, these changes can be done in real time, causing the currency of the data base to be limited only by the diligence of the employer. me fact that the data base is current has two significant results: first, the average lag period of fifteen days, discussed above, is eliminated. Therefore, a former employee cannot exploit the existence of the lag and obtain trea-tment, because treating physicians will be able to know immediately when an employee is deleted from the roster of insured persons.
A second result relates ~ COBRA requirements. The occurrence of updates to the roster can trigger the notification procedure described above into actionO For example, detection routine, or cixcuit, known in the art, detect~ a deletion of a perso~ from the roster and, in response, immediately causes a notification to be sent, as outlined in Table 1. The immediate notification prevents COBRA mandated insurance from arising at the employer's expense.
These two results are similar in the respect that they both limit the liability, borne by an employer, which arises through the running of time. Viewed another way, the same event which eliminates the fifteen-day lag in insurance termination ~i.e., the event of real-time deletion from the roster) also triggers into action the notification , procedure of Table 1.
2. The computation of the patient's bill, discussed in connection with block 118 in FiguLe 3B, includes a computation of any deductible amount owed by the patient. mis is possible because the administration computer retains records of all insurance activity by the patient Adam. For example, i~ Adam has a One Hundred Dollar deductible -- -`-~ S$7~ .
t ~ . .
.''' . .
amount Fer year, if Adam has received no other treatment in the year, and if the charge for the present treat~ent is Eighty Dollars, the entire Eighty Dollar8 i~ paid by Adam ~ Thls fac~ is indicated on the bill printed by terminal 18 in Figure 1.
Block 118 also indicate~ the administration computer calculates any co-payment amounts. This refers to amounts which the patient may be required to co-pay with the plan ABC. For example, Plan AEC may pay fully for treatments for sprained wrists, but only pay one-half for cosmetic facial surgery. In the latter case, thel patient co-pays the .' , ', I .
remaining one-half 3. The preceding discussion has been made in the context of a patient visiting a physician. Howe~er, it should be understood that -the invention can be used by any provlder of health care services, including physicians, dentists, hospitals, pharmacists, podiatrists, chiropodists, and psychologists. In this respect, a programming routine can be added which examines whether the given provider is authorized to perform the treatment for which payment is sought. For example, a podiatrist may not ke authorized by state law to perform some types of surgery. m e limits on the treatments which a provider can perform are stored in the administration computer, and are retrieved at the time the identity of the provider is verified, in block 63 in Figure 2B. m e routine prevents payments to unauthori2ed providers~
4. The card 15 in Figure 1, which is carried by the patient, is the only card used by him, irrespective of the type of health benefits sought. Ihat is, the patient presents the same card to his dentist, his pharmacist, his psychblogist, etc.
., ~ 2~5~
5. A telephone connection between the physician's terminal 18 and the administration computer, and also between the administration computer and the employer, has been discussed. The preferred telephone connection uses a communications network, known in the art, such as Tymnet, available from McDonnel Douglas Corporation. The network allows a physician in one city to communicate with the administration computer located in a different city, by making a local, non-toll, telephone call.
Line 1 in Table 1 indicates that the Adams ~amily is deleted from the roster of insured persons under the ABC plan, perhaps because of termination of employment. This is done directly by the empioyer or data link 24. One significant consequence of this deletion from the :
~ ~$~ sJ~
~roster is that, should a physician make inquiry using the physician's data link 21, the administration computer has information, almost on an imn~diate basis, allowing the computer to inform the physician that the Adams family i5 no longer covered by the ABC plan. However, in some cases, discussed later, the computer may refrain from stating tha-t the family is not covered by the ABC plan, and instead indicate that the family presently has an mdeterminate status as to coverage.
Upon deletion of the Adams' participants from the plan, and if the employer so requests, either at the time of deletion, or at a prior time, administration computer 3 activates a printer 170 which prints a notice which i5 transmitted to one or more members of the family, notify-ing them of the fact of termination, and offering them the option to purchase within a stated period of time the same or similar insurance which they previously had, at stated premium rates. The letter is transmitted to the Adams family~ and the admhlistration computer then sets into motion a programming routine, known in the art, to track the response of the Adam's family, when it occurs.
If one or more of the family me~bers respond favorably, in writing, an operator enters the proper data into the administration computer. In response, the computer, using printer 170, prints a group of payment coupons, which are mailed to the electing participants. The participants return the coupons with payment, on a periodic basis, and the coupons assist the administration computer in tracking the payment history of the electing participants. The co~pons bear sufficient ! information to do this, and can be machine-readable by the administration computer, as known in the art.
If no response is received in the stated time, the computerr having an internal time clock, as known in the art, notifies the data base for plan ABC, an~ programming steps are taken to change the status 5~
of the Adams family ~rom indeterminate to terminated, as will now be discussed.
As was stated earlier, it may be the case that an option was given to the Adams family to elect to purchase insurance within a stated time period. This option can be given in fulfillment of a collective bargaining agreement, state or federal statutes, as discussed earlier, or for other reasons. Further, the option may have certain retroactive aspects. For example, the employer may be required to give the former employee the right to exercise the option for a stated period of time, such as sixty days. If the option is retroactive, the following sequence of events can occ~r. Termination of emplo~ment can occur on July l. The notice described in ~ine 2 of Table 1 can be sent on the same day, July 1. The notice can be received by the employee on ~uly 2 and the notice can give him sixty days within which to decide whether to purchase insurance. The employee may visit a physician on July lS, but before he exercised the option~ If he exercises the option on July 20, and pays the insurance premium as re~uired, the ABC plan may be required to pay for the July 15 visit to the physician. Therefore, the administration computer, ln searching the data base in response to ~he physician's inquiry on ~uly 15, classifies the Adams family as indeterminate until the option is exercised, or the option expires.
Continuing the example, if the option expires on September 1, without being exercised, and if Adams visits a physician on Septen~er 10, the a~ninistration computer, in response to the physician's inquiry states that Adams is terminated from the ABC plan, and not under indeter-minate status. Further, the classification was made by the computer immediately upon expiration of the option, which was a stated period, (sixty days in this case) after malling of the notice discussed in Line 2 of Table 1.
` Several important aspects of the invention are the following;
1. As Figure 1 indicates, an employer can add and delete beneficiaries, as well as change provisions of a plan, by using data link 24. Further, as the discussion above indicates, these changes can be done in real time, causing the currency of the data base to be limited only by the diligence of the employer. me fact that the data base is current has two significant results: first, the average lag period of fifteen days, discussed above, is eliminated. Therefore, a former employee cannot exploit the existence of the lag and obtain trea-tment, because treating physicians will be able to know immediately when an employee is deleted from the roster of insured persons.
A second result relates ~ COBRA requirements. The occurrence of updates to the roster can trigger the notification procedure described above into actionO For example, detection routine, or cixcuit, known in the art, detect~ a deletion of a perso~ from the roster and, in response, immediately causes a notification to be sent, as outlined in Table 1. The immediate notification prevents COBRA mandated insurance from arising at the employer's expense.
These two results are similar in the respect that they both limit the liability, borne by an employer, which arises through the running of time. Viewed another way, the same event which eliminates the fifteen-day lag in insurance termination ~i.e., the event of real-time deletion from the roster) also triggers into action the notification , procedure of Table 1.
2. The computation of the patient's bill, discussed in connection with block 118 in FiguLe 3B, includes a computation of any deductible amount owed by the patient. mis is possible because the administration computer retains records of all insurance activity by the patient Adam. For example, i~ Adam has a One Hundred Dollar deductible -- -`-~ S$7~ .
t ~ . .
.''' . .
amount Fer year, if Adam has received no other treatment in the year, and if the charge for the present treat~ent is Eighty Dollars, the entire Eighty Dollar8 i~ paid by Adam ~ Thls fac~ is indicated on the bill printed by terminal 18 in Figure 1.
Block 118 also indicate~ the administration computer calculates any co-payment amounts. This refers to amounts which the patient may be required to co-pay with the plan ABC. For example, Plan AEC may pay fully for treatments for sprained wrists, but only pay one-half for cosmetic facial surgery. In the latter case, thel patient co-pays the .' , ', I .
remaining one-half 3. The preceding discussion has been made in the context of a patient visiting a physician. Howe~er, it should be understood that -the invention can be used by any provlder of health care services, including physicians, dentists, hospitals, pharmacists, podiatrists, chiropodists, and psychologists. In this respect, a programming routine can be added which examines whether the given provider is authorized to perform the treatment for which payment is sought. For example, a podiatrist may not ke authorized by state law to perform some types of surgery. m e limits on the treatments which a provider can perform are stored in the administration computer, and are retrieved at the time the identity of the provider is verified, in block 63 in Figure 2B. m e routine prevents payments to unauthori2ed providers~
4. The card 15 in Figure 1, which is carried by the patient, is the only card used by him, irrespective of the type of health benefits sought. Ihat is, the patient presents the same card to his dentist, his pharmacist, his psychblogist, etc.
., ~ 2~5~
5. A telephone connection between the physician's terminal 18 and the administration computer, and also between the administration computer and the employer, has been discussed. The preferred telephone connection uses a communications network, known in the art, such as Tymnet, available from McDonnel Douglas Corporation. The network allows a physician in one city to communicate with the administration computer located in a different city, by making a local, non-toll, telephone call.
6. If the patient has recently terminated employment, and then seeks medical treatment, the administration computer, as outlined in Table 1, records the patient's insurance status as indeterminate and informs the physician accordingly. In such a case, the physician must decide the manner in which to collect payment, as plan ABC makes no commitment at this time. ,~
7. The invention has been described in terms of health benefits claims. However, it is applicable to any generic plan under which a third party pays money for ~he benefit of a beneficiary. One example is a food stamp program, in which a beneficiary presents food stamps (i.e., the "card" 15 in Figure 1) to a supermarket tthe "provider") which can ~erify, using terminal 18, whether the s-tamps are valid, and whether the beneficiary is entitled to use them. In this case, the roster is a roster of food stamp beneficiaries.
In another example, a governmental workman's compensation program is treated as analogous to plan ABC, and provides payment.
In another example, a governmental workman's compensation program is treated as analogous to plan ABC, and provides payment.
8. In addition to the verification procedures described above for verifying the identity of the patient, other procedures can be used.
Voiceprintr fingerp~int, and signature verification can be used, as known in the art.
- -'5~37~
From one point of view, the invention allows the physician to only address and read the data base, while the employer can address, read, and, in addition, modify the data base, as by deleting beneficiaries. (Of course, ~he physician, in ~ sense, can modify the data base, ~ecause the treatments which he performs are stored by the admini~tration computer. However, this type of modification does not affect the benefits available to beneficiaries. The employer can modify the benefits.
10. Figure 4 describes an optional procedure by which a E~tient can pay the balance which plan AEC does not cover. Figure 5 describes a procedure by which plan ABC pays the physician.
11. Plan ABC has been described as an insurance plan. However, it need not be such. Plan ABC can be a self-insurance plan of the ~mployer, or any entity which provides benefits to beneficiaries for specified types of health care.
An invention has been described wherein a physician, at the time and location of rendering medical treatment, obtains information as to the amount of payment for the treatment, and also, in some cases, actual payment itself~ m e information is obtained from a database which is updated, in real time, by the employer providing the insurance.
Numerous substitutions and modifications can be undertaken without departing from the tr~e spirit and scope of the invention as defined in the claims. What is desired to be covered by Letters Patent is the invention as defined in the following claims.
Voiceprintr fingerp~int, and signature verification can be used, as known in the art.
- -'5~37~
From one point of view, the invention allows the physician to only address and read the data base, while the employer can address, read, and, in addition, modify the data base, as by deleting beneficiaries. (Of course, ~he physician, in ~ sense, can modify the data base, ~ecause the treatments which he performs are stored by the admini~tration computer. However, this type of modification does not affect the benefits available to beneficiaries. The employer can modify the benefits.
10. Figure 4 describes an optional procedure by which a E~tient can pay the balance which plan AEC does not cover. Figure 5 describes a procedure by which plan ABC pays the physician.
11. Plan ABC has been described as an insurance plan. However, it need not be such. Plan ABC can be a self-insurance plan of the ~mployer, or any entity which provides benefits to beneficiaries for specified types of health care.
An invention has been described wherein a physician, at the time and location of rendering medical treatment, obtains information as to the amount of payment for the treatment, and also, in some cases, actual payment itself~ m e information is obtained from a database which is updated, in real time, by the employer providing the insurance.
Numerous substitutions and modifications can be undertaken without departing from the tr~e spirit and scope of the invention as defined in the claims. What is desired to be covered by Letters Patent is the invention as defined in the following claims.
Claims (25)
1. In a health care benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, the improvement comprising:
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state.
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state.
2. The administration system of claim 1 wherein the adminstration system is accessible to service providers which provide medical services to patients, the improvement further comprising:
at least one service provider terminal communicating on line with said computer system and directly accessible by said service provider for input of data indicating the identity of a patient and for receiving from said computer system an indication of the eligibility of said patient for medical benefits;
said computer system being preprogrammed to interrogate said status record in response to input of data from said service provider terminal and to supply indication at said service provider terminal of whether said status record for said patient is at said pending state.
at least one service provider terminal communicating on line with said computer system and directly accessible by said service provider for input of data indicating the identity of a patient and for receiving from said computer system an indication of the eligibility of said patient for medical benefits;
said computer system being preprogrammed to interrogate said status record in response to input of data from said service provider terminal and to supply indication at said service provider terminal of whether said status record for said patient is at said pending state.
3. The benefits system of claim 1 wherein said status record is capable of storing a special active state in addition to said active state and said pending state, said special active state indicating that a given patient has been terminated by the benefits sponsor and said patient has elected to continue to receive medical benefits.
4. The administration system of claim 3 wherein said status record is further capable of storing a terminated state in addition to said active state, said special active state and said pending state;
wherein said computer system includes time clock means for ascertaining elapsed time; and wherein said computer system is preprogrammed to interrogate said status record and to automatically change a pending state to a terminated state in response to a predetermined elapsed time.
wherein said computer system includes time clock means for ascertaining elapsed time; and wherein said computer system is preprogrammed to interrogate said status record and to automatically change a pending state to a terminated state in response to a predetermined elapsed time.
5. The administration system of claim 1 wherein said status record is capable of storing a terminated state in addition to said active state and said pending state;
wherein said computer system includes time clock means for ascertaining elapsed time; and wherein said computer system is preprogrammed to interrogate said status record and to automatically change a pending state to a terminated state in response to a predetermined elapsed time.
wherein said computer system includes time clock means for ascertaining elapsed time; and wherein said computer system is preprogrammed to interrogate said status record and to automatically change a pending state to a terminated state in response to a predetermined elapsed time.
6. The administration system of claim 1 wherein said computer system includes time clock means for ascertaining elapsed time; and wherein said computer system is preprogrammed to interrogate said status record and to automatically remove a patient from said eligibility file when said status record for that patient has been in the pending state for a predetermined elapsed time.
7. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:
said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage.
said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage.
8. The administration system of claim 7 wherein said patient file includes a record capable of identifying one of a plurality of medical benefits plans as a primary plan and at least one other of said plurality of medical benefits plans as a secondary plan; and wherein said computer system is preprogrammed to coordinate benefits for a given patient between said primary and secondary plans.
9. The administration system of claim 7 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the eligibility of said patient for medical benefits.
10. The administration system of claim 7 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the amounts payable under such medical benefits plans for the services indicated by said service data.
11. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by sevice providers in interacting with said computer system, the improvement comprising:
said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;
said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage.
said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data.
said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;
said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage.
said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data.
12. The administration system of claim 11 wherein said patient file includes a record capable of identifying one of a plurality of medical benefits plans as a primary plan and at least one other of said plurality of medical benefits plans as a secondary plan; and wherein said computer system is preprogrammed to coordinate benefits fro a given patient between said primary and secondary plans.
13. The administration system of claim 11 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the eligibility of said patient for medical benefits.
14. The administration system of claim 11 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the amounts payable under such medical benefits plans for the services indicated by said service data.
15. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:
said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for providing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data.
said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for providing one of a plurality of states, including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data.
16. The administration system of claim 15 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the eligibility of said patient for medical benefits.
17. The administration system of claim 15 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the amounts payable under such medical benefits plans for the services indicated by said service data.
18. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:
said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;
said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;
said database having means for establishing a hierarchy among each of said plurality of medical benefits plans for a given patient, identifying at least a primary plan and a secondary plan;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patients;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage;
said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data;
said computer system being preprogrammed to access said hierarchy establishing means in so determining the amounts payable, whereby said secondary plan is applied to amounts not payable under said primary plan to thereby maximize the total amounts payable on behalf of said patient without cumulative overpayment by said primary and secondary plans.
said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;
said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;
said database having means for establishing a hierarchy among each of said plurality of medical benefits plans for a given patient, identifying at least a primary plan and a secondary plan;
said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;
said eligibility file including a benefits status record for storing one of a plurality of states including at least an active state and a pending state, for each patient;
a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;
said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;
said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patients;
notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;
said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;
said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage;
said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data;
said computer system being preprogrammed to access said hierarchy establishing means in so determining the amounts payable, whereby said secondary plan is applied to amounts not payable under said primary plan to thereby maximize the total amounts payable on behalf of said patient without cumulative overpayment by said primary and secondary plans.
19. A method of updating a central data base consisting of the identities of beneficiaries who at a point in time are members of an employment group having post-membership option rights for continuing health care benefits comprising the steps of:
establishing a file of predetermined time spans between active and pending states of benefit plan eligibility based on the status of association between the beneficiary and the employment group; and utilizing a clock function, updating the beneficiary plan eligibility state in the file; and establishing a two-way data communication link between at least one benefit provider and the file whereby a provider can input member identification information and receive current data representing the status of the beneficiary relevant to the employment group and plan eligibility during both active and pending status periods.
establishing a file of predetermined time spans between active and pending states of benefit plan eligibility based on the status of association between the beneficiary and the employment group; and utilizing a clock function, updating the beneficiary plan eligibility state in the file; and establishing a two-way data communication link between at least one benefit provider and the file whereby a provider can input member identification information and receive current data representing the status of the beneficiary relevant to the employment group and plan eligibility during both active and pending status periods.
20. A method as defined in claim 19 further including the step of generating a notification to a group member upon the occurrence of a change in status.
21. A method as defined in claim 20 wherein the notification includes information regarding continuing benefit plan options.
22. For use in combination with a central data base which is maintained by a health care benefit plan administrator and which consists of at least (a) employment group member identification data, (b) employment group member benefit eligibility status data, (c) defined benefit payment amounts and (d) a clock function which modifies the plan eligibility status data for individual employment group members at appropriate times related to a change in employment group membership status:
a two-way data communication apparatus for location at a benefit provider station which is remote from the central data base and which includes:
means for inputting beneficiary identification data and sending such identification data to the central data base for verification as to the association between the proposed beneficiary and the employment group benefit plan and, according to said clock function, the status of beneficiary eligibility;
means for receiving and displaying proposed beneficiary eligibility confirmation from the central data base as a result of the inputting of beneficiary identification data;
means for inputting proposed benefit identification data and sending such benefit identification data to the central data base;
means for receiving and displaying the payment amount data from the central data base which corresponds to the previously inputted proposed benefit identification data; and means for inputting and sending to the central data base a payment request based on the proposed benefit payment amount.
a two-way data communication apparatus for location at a benefit provider station which is remote from the central data base and which includes:
means for inputting beneficiary identification data and sending such identification data to the central data base for verification as to the association between the proposed beneficiary and the employment group benefit plan and, according to said clock function, the status of beneficiary eligibility;
means for receiving and displaying proposed beneficiary eligibility confirmation from the central data base as a result of the inputting of beneficiary identification data;
means for inputting proposed benefit identification data and sending such benefit identification data to the central data base;
means for receiving and displaying the payment amount data from the central data base which corresponds to the previously inputted proposed benefit identification data; and means for inputting and sending to the central data base a payment request based on the proposed benefit payment amount.
23. Apparatus as defined in claim 22 further including a two-way data communication link between said device and the central data base.
24. Apparatus as defined in claim 23 further including means for updating the contents of the central data base to show both active and pending states of benefit plan eligibility for each beneficiary whose identification data is in the central data base.
25. Apparatus as defined in claim 24 further including notice generating means interconnected with said central data base for receiving data representing changes in status of a beneficiary relative to the employment group and for generating notices of benefit plan eligibility and options associated with said eligibility for transmission to beneficiaries/employment group members; and clock means for initiating activation of said notice generating means a regulated time span following an employment group membership status change.
Applications Claiming Priority (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| US07/068,240 US4916611A (en) | 1987-06-30 | 1987-06-30 | Insurance administration system with means to allow an employer to directly communicate employee status data to centralized data storage means |
| US068,240 | 1987-06-30 |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CA1285070C true CA1285070C (en) | 1991-06-18 |
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| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CA000570175A Expired - Lifetime CA1285070C (en) | 1987-06-30 | 1988-06-23 | Insurance administration system |
Country Status (6)
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| US (1) | US4916611A (en) |
| EP (1) | EP0297780A3 (en) |
| JP (1) | JPH0192867A (en) |
| AU (2) | AU604550B2 (en) |
| CA (1) | CA1285070C (en) |
| NZ (1) | NZ225213A (en) |
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-
1987
- 1987-06-30 US US07/068,240 patent/US4916611A/en not_active Expired - Lifetime
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1988
- 1988-06-23 CA CA000570175A patent/CA1285070C/en not_active Expired - Lifetime
- 1988-06-23 EP EP88305729A patent/EP0297780A3/en not_active Withdrawn
- 1988-06-24 AU AU18392/88A patent/AU604550B2/en not_active Expired
- 1988-06-29 JP JP63162382A patent/JPH0192867A/en active Pending
- 1988-06-29 NZ NZ225213A patent/NZ225213A/en unknown
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1991
- 1991-01-02 AU AU68642/91A patent/AU629084B2/en not_active Expired
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|---|---|
| US4916611A (en) | 1990-04-10 |
| AU604550B2 (en) | 1990-12-20 |
| JPH0192867A (en) | 1989-04-12 |
| EP0297780A3 (en) | 1990-08-22 |
| NZ225213A (en) | 1995-07-26 |
| EP0297780A2 (en) | 1989-01-04 |
| AU1839288A (en) | 1989-01-05 |
| AU6864291A (en) | 1991-03-14 |
| AU629084B2 (en) | 1992-09-24 |
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