WO2007002611A3 - Healthcare claims loss control systems and methods - Google Patents
Healthcare claims loss control systems and methods Download PDFInfo
- Publication number
- WO2007002611A3 WO2007002611A3 PCT/US2006/024860 US2006024860W WO2007002611A3 WO 2007002611 A3 WO2007002611 A3 WO 2007002611A3 US 2006024860 W US2006024860 W US 2006024860W WO 2007002611 A3 WO2007002611 A3 WO 2007002611A3
- Authority
- WO
- WIPO (PCT)
- Prior art keywords
- loss control
- payment
- healthcare
- control engine
- database
- Prior art date
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
- G06Q10/00—Administration; Management
- G06Q10/10—Office automation; Time management
-
- 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
- G06Q20/00—Payment architectures, schemes or protocols
- G06Q20/38—Payment protocols; Details thereof
- G06Q20/40—Authorisation, e.g. identification of payer or payee, verification of customer or shop credentials; Review and approval of payers, e.g. check credit lines or negative lists
- G06Q20/401—Transaction verification
- G06Q20/4016—Transaction verification involving fraud or risk level assessment in transaction processing
-
- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q30/00—Commerce
- G06Q30/018—Certifying business or products
- G06Q30/0185—Product, service or business identity fraud
-
- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q30/00—Commerce
- G06Q30/02—Marketing; Price estimation or determination; Fundraising
- G06Q30/0207—Discounts or incentives, e.g. coupons or rebates
- G06Q30/0225—Avoiding frauds
-
- 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
Abstract
A method for controlling healthcare claim payment losses including accessing information about a claim (5) after a payer is prepared to pay (30), but prior to payment (40), evaluating the information including at least one of determining indications of fraud (101), validating service coding and editing as indicated (103), identifying possible payment discounts (105, 107), and developing analytics indicative of risk for future claims (109), and providing loss control recommendations (140) based at least partially on the evaluation, prior to paying the claim (40). Also a loss control system for healthcare claims with a loss control engine (110) and a database in communication with the loss control engine (110), wherein the loss control engine (110) accesses information about healthcare claims (5) from the database after the claims have been processed for payment (30) and wherein the loss control engine (110) further analyses the claims for potential cost savings and returns a loss control recommendation (140) for each claim to the database before payment (40) of the respective claim.
Applications Claiming Priority (2)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
US69418205P | 2005-06-27 | 2005-06-27 | |
US60/694,182 | 2005-06-27 |
Publications (2)
Publication Number | Publication Date |
---|---|
WO2007002611A2 WO2007002611A2 (en) | 2007-01-04 |
WO2007002611A3 true WO2007002611A3 (en) | 2007-07-12 |
Family
ID=37595957
Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
---|---|---|---|
PCT/US2006/024860 WO2007002611A2 (en) | 2005-06-27 | 2006-06-26 | Healthcare claims loss control systems and methods |
Country Status (2)
Country | Link |
---|---|
US (5) | US20070011030A1 (en) |
WO (1) | WO2007002611A2 (en) |
Families Citing this family (48)
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US9269117B2 (en) | 2005-05-10 | 2016-02-23 | Mckesson Technologies Inc. | Enterprise management system |
US8578500B2 (en) * | 2005-05-31 | 2013-11-05 | Kurt James Long | System and method of fraud and misuse detection |
US20070011030A1 (en) * | 2005-06-27 | 2007-01-11 | Bregante George J | Systems and methods for scoring loss control opportunities in healthcare claims |
US20070192132A1 (en) | 2006-02-10 | 2007-08-16 | Debra Thesman | System and method of prioritizing and administering healthcare to patients having multiple integral diagnoses |
US20080120133A1 (en) * | 2006-11-21 | 2008-05-22 | Arvind Krishnaswami | Method for predicting the payment of medical debt |
US8285656B1 (en) | 2007-03-30 | 2012-10-09 | Consumerinfo.Com, Inc. | Systems and methods for data verification |
US20090076960A2 (en) * | 2007-05-16 | 2009-03-19 | Medicalmanagement Technology Group, Inc. | Method, systemand computer program product fordetecting and preventing fraudulent health care claims |
US20090228300A1 (en) * | 2007-05-16 | 2009-09-10 | Medical Management Technology Group, Inc. | Mobile device-enhanced verification of medical transportation services |
US8103527B1 (en) * | 2007-06-29 | 2012-01-24 | Intuit Inc. | Managing insurance claim data across insurance policies |
US8086474B1 (en) * | 2007-07-30 | 2011-12-27 | Intuit Inc. | Managing insurance claim data |
US20100145734A1 (en) * | 2007-11-28 | 2010-06-10 | Manuel Becerra | Automated claims processing system |
US20090222290A1 (en) * | 2008-02-29 | 2009-09-03 | Crowe Michael K | Methods and Systems for Automated, Predictive Modeling of the Outcome of Benefits Claims |
US8312033B1 (en) | 2008-06-26 | 2012-11-13 | Experian Marketing Solutions, Inc. | Systems and methods for providing an integrated identifier |
US20100179838A1 (en) * | 2009-01-15 | 2010-07-15 | Nitin Basant | Healthcare service provider insurance claim fraud and error detection using co-occurrence |
US8224678B2 (en) * | 2009-01-20 | 2012-07-17 | Ametros Financial Corporation | Systems and methods for tracking health-related spending for validation of disability benefits claims |
US20110112873A1 (en) * | 2009-11-11 | 2011-05-12 | Medical Present Value, Inc. | System and Method for Electronically Monitoring, Alerting, and Evaluating Changes in a Health Care Payor Policy |
US20130085769A1 (en) * | 2010-03-31 | 2013-04-04 | Risk Management Solutions Llc | Characterizing healthcare provider, claim, beneficiary and healthcare merchant normal behavior using non-parametric statistical outlier detection scoring techniques |
US10002391B1 (en) * | 2010-10-11 | 2018-06-19 | Pionetechs, Inc. | Method for detecting and preventing fraudulent healthcare claims |
US20120191468A1 (en) * | 2011-01-21 | 2012-07-26 | Joseph Blue | Apparatuses, Systems, and Methods for Detecting Healthcare Fraud and Abuse |
US20120329015A1 (en) | 2011-06-24 | 2012-12-27 | Debra Thesman | Hierarchical condition categories program |
US10372878B2 (en) * | 2011-06-30 | 2019-08-06 | Verizon Patent And Licensing Inc. | Secure communications |
US8738399B1 (en) * | 2011-12-30 | 2014-05-27 | Express Scripts, Inc. | Methods and systems for drug purchase validation |
US20140149128A1 (en) * | 2012-11-29 | 2014-05-29 | Verizon Patent And Licensing Inc. | Healthcare fraud detection with machine learning |
US20140149142A1 (en) * | 2012-11-29 | 2014-05-29 | Fair Isaac Corporation | Detection of Healthcare Insurance Claim Fraud in Connection with Multiple Patient Admissions |
US10600516B2 (en) | 2012-12-12 | 2020-03-24 | Advanced Healthcare Systems, Inc. | Healthcare administration method for complex case and disease management |
US10424032B2 (en) | 2012-12-12 | 2019-09-24 | Quality Standards, Llc | Methods for administering preventative healthcare to a patient population |
US20140164003A1 (en) | 2012-12-12 | 2014-06-12 | Debra Thesman | Methods for optimizing managed healthcare administration and achieving objective quality standards |
US20140236614A1 (en) * | 2013-02-15 | 2014-08-21 | Passport Health Communications, Inc. | Financial Triage |
US20150127370A1 (en) * | 2013-11-06 | 2015-05-07 | ClaimReturn, LLC | System and Method for Identifying and Correcting Billing Errors in High-Volume Billing and Claim Adjudicating Systems |
US10262362B1 (en) | 2014-02-14 | 2019-04-16 | Experian Information Solutions, Inc. | Automatic generation of code for attributes |
US9009827B1 (en) | 2014-02-20 | 2015-04-14 | Palantir Technologies Inc. | Security sharing system |
US20150235334A1 (en) * | 2014-02-20 | 2015-08-20 | Palantir Technologies Inc. | Healthcare fraud sharing system |
US9836794B2 (en) | 2014-04-21 | 2017-12-05 | Hartford Fire Insurance Company | Computer system and method for detecting questionable service providers |
US10706963B2 (en) | 2014-09-09 | 2020-07-07 | Cambria Health Solutions, Inc. | Systems and methods for a health care E-commerce marketplace |
US9727869B1 (en) * | 2015-06-05 | 2017-08-08 | Square, Inc. | Expedited point-of-sale merchant payments |
US11430070B1 (en) | 2017-07-31 | 2022-08-30 | Block, Inc. | Intelligent application of reserves to transactions |
BR112019015920A8 (en) | 2017-01-31 | 2020-04-28 | Experian Inf Solutions Inc | massive heterogeneous data ingestion and user resolution |
US11670413B2 (en) * | 2017-03-28 | 2023-06-06 | Aspire Smart Health-Lancaster, Llc | Resource efficient computer-implemented surgical resource allocation system and method |
US10915900B1 (en) | 2017-06-26 | 2021-02-09 | Square, Inc. | Interchange action delay based on refund prediction |
US10949842B1 (en) * | 2018-01-30 | 2021-03-16 | Mastercard International Incorporated | Preventing data analysis interruptions by identifying card continuity without using personally identifiable information |
US10565660B2 (en) * | 2018-02-07 | 2020-02-18 | Sunbelt Medical Management, Llc | Medical claim database relationship processing |
US10963434B1 (en) | 2018-09-07 | 2021-03-30 | Experian Information Solutions, Inc. | Data architecture for supporting multiple search models |
US11257018B2 (en) * | 2018-12-24 | 2022-02-22 | Hartford Fire Insurance Company | Interactive user interface for insurance claim handlers including identifying insurance claim risks and health scores |
US11645344B2 (en) | 2019-08-26 | 2023-05-09 | Experian Health, Inc. | Entity mapping based on incongruent entity data |
US11941065B1 (en) | 2019-09-13 | 2024-03-26 | Experian Information Solutions, Inc. | Single identifier platform for storing entity data |
US11880377B1 (en) | 2021-03-26 | 2024-01-23 | Experian Information Solutions, Inc. | Systems and methods for entity resolution |
Citations (5)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
US5359509A (en) * | 1991-10-31 | 1994-10-25 | United Healthcare Corporation | Health care payment adjudication and review system |
US20030149594A1 (en) * | 2001-04-13 | 2003-08-07 | Beazley Donald E. | System and method for secure highway for real-time preadjudication and payment of medical claims |
US20040111292A1 (en) * | 2002-12-06 | 2004-06-10 | Hutchins Patton A. | Healthcare credit evaluation method |
US6826536B1 (en) * | 2000-07-22 | 2004-11-30 | Bert Forman | Health care billing monitor system for detecting health care provider fraud |
US20050044357A1 (en) * | 2003-08-13 | 2005-02-24 | Fano Andrew E. | Fraud detection method and system |
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US5577169A (en) * | 1994-04-29 | 1996-11-19 | International Business Machines Corporation | Fuzzy logic entity behavior profiler |
US6253186B1 (en) * | 1996-08-14 | 2001-06-26 | Blue Cross Blue Shield Of South Carolina | Method and apparatus for detecting fraud |
US6208973B1 (en) * | 1998-02-27 | 2001-03-27 | Onehealthbank.Com | Point of service third party financial management vehicle for the healthcare industry |
US6343271B1 (en) * | 1998-07-17 | 2002-01-29 | P5 E.Health Services, Inc. | Electronic creation, submission, adjudication, and payment of health insurance claims |
US6341265B1 (en) * | 1998-12-03 | 2002-01-22 | P5 E.Health Services, Inc. | Provider claim editing and settlement system |
US6792410B1 (en) * | 1999-05-07 | 2004-09-14 | Hfn, Inc. | Automated claim repricing system |
US7881962B2 (en) * | 2000-03-14 | 2011-02-01 | Verizon Business Global Llc | Early-payment discount for E-billing system |
US7359880B2 (en) * | 2000-07-11 | 2008-04-15 | Abel Luther C | System and method for consumer control over card-based transactions |
CA2485034C (en) * | 2002-05-16 | 2016-07-12 | Ndchealth Corporation | Systems and methods for verifying and editing electronically transmitted claim content |
US20060217824A1 (en) * | 2005-02-25 | 2006-09-28 | Allmon Andrea L | Fraud, abuse, and error detection in transactional pharmacy claims |
US20070011030A1 (en) * | 2005-06-27 | 2007-01-11 | Bregante George J | Systems and methods for scoring loss control opportunities in healthcare claims |
-
2006
- 2006-06-26 US US11/426,524 patent/US20070011030A1/en not_active Abandoned
- 2006-06-26 US US11/426,529 patent/US20070011032A1/en not_active Abandoned
- 2006-06-26 WO PCT/US2006/024860 patent/WO2007002611A2/en active Application Filing
- 2006-06-26 US US11/426,527 patent/US7873528B2/en active Active
-
2011
- 2011-01-14 US US13/006,927 patent/US8229770B2/en active Active
-
2012
- 2012-07-17 US US13/551,225 patent/US20120284044A1/en not_active Abandoned
Patent Citations (5)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
US5359509A (en) * | 1991-10-31 | 1994-10-25 | United Healthcare Corporation | Health care payment adjudication and review system |
US6826536B1 (en) * | 2000-07-22 | 2004-11-30 | Bert Forman | Health care billing monitor system for detecting health care provider fraud |
US20030149594A1 (en) * | 2001-04-13 | 2003-08-07 | Beazley Donald E. | System and method for secure highway for real-time preadjudication and payment of medical claims |
US20040111292A1 (en) * | 2002-12-06 | 2004-06-10 | Hutchins Patton A. | Healthcare credit evaluation method |
US20050044357A1 (en) * | 2003-08-13 | 2005-02-24 | Fano Andrew E. | Fraud detection method and system |
Also Published As
Publication number | Publication date |
---|---|
US20120284044A1 (en) | 2012-11-08 |
US20070011032A1 (en) | 2007-01-11 |
US20110112859A1 (en) | 2011-05-12 |
US7873528B2 (en) | 2011-01-18 |
US8229770B2 (en) | 2012-07-24 |
US20070011030A1 (en) | 2007-01-11 |
WO2007002611A2 (en) | 2007-01-04 |
US20070011031A1 (en) | 2007-01-11 |
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