Electrical computers and digital processing systems: multicomput – Computer-to-computer protocol implementing – Computer-to-computer data framing
Reexamination Certificate
2000-06-05
2001-03-06
Peeso, Thomas R. (Department: 2767)
Electrical computers and digital processing systems: multicomput
Computer-to-computer protocol implementing
Computer-to-computer data framing
C709S237000, C709S245000, C709S246000
Reexamination Certificate
active
06199115
ABSTRACT:
BACKGROUND OF THE INVENTION
The present invention relates generally to an attachment integrated claims (AIC) system for preparing and processing forms with integrated attachments. More specifically, the present invention relates to a Customizable Claim Form, i.e., a Dynamic Claim Form (DCF) suitable for use with an AIC system. A method of operating a totally digital AIC system while employing a DCF is also disclosed.
High administrative costs for filing and processing health insurance claims have been the bane of the health insurance industry from its inception. Over the years, many attempts have been made to develop a faster and more cost effective claims processing system. Three stages in this development effort are described in the following correspondingly numbered paragraphs.
(1) The original system involved hard copy paper claims only, with transmission and all processing done manually. Originally, an insurance claim was filed by the patient or the health care provider filling out a paper form. The completed paper form was then mailed to the insurance company. At the insurance company, the paper claim form went through a series of administrative steps, all the time remaining as a hard copy paper object. When a decision was made, the decision was written up and archived with the claim form; a hard copy was also sent to the patient and/or provider along with the payment.
(2) The first significant advancement resulted from the introduction of the mainframe computer. This allowed for electronic processing within a given insurance company, i.e., once the claim was on the computer inside the company, the paper form could be dispensed with. Computerization is a highly effective way of reducing administrative overhead in claims processing.
Thus, mainframe computers were purchased and installed internally at the insurance companies. Since these computers were intended for internal use only, each company thought only of its own needs and either developed proprietary claims processing software or had claims management software purchased from an outside source customized to meet the insurance company's claims processing methodology. While the claims management software for a number of insurance companies would be written in the same high-level programming language, e.g., COBOL, the similarity between software programs often ended there.
There were many virtues to these early systems, primarily with respect to decreased administrative costs, but a major drawback was that the data for each “paper” claim had to be entered into the computer to form an electronic claim. This necessitated the manual transcription of exactly the same information that had been entered into the original paper claim before it was sent to the insurance company.
(3) The next advancement was the electronic filing of claim forms. This was made possible by the introduction of the personal computer and modem into the provider's office. The main purpose of this stage was to eliminate the manual re-entry of information into the insurance company mainframe.
The basic idea was to have the providers fill out an electronic claim form, instead of a paper claim form. This electronic form, which would be stored in the memory of their PCs, would then be transmitted, as a computer file, to the insurance company. It could then be integrated directly into the electronic claims processing system without the manual re-entry of data. Thus, the technology existed to produce a system that computerized the overall filing and processing of the insurance claim from the point of entry, the provider's office, to the final report of the claims adjuster.
Although the idea was straightforward, implementation was not. Two basic problems had to be overcome in order to create a viable system. First, the information contained in the electronic claim form had to be integrated into the claims processing software at the insurance company. Second, a majority of providers have to be able to interface with a majority of insurance companies, i.e., insurance company mainframe computers. However, because of the way computers were introduced into the insurance industry originally (stage #2), there was no industry-wide standard, i.e., the legacy mainframe computers of the different insurance companies were incompatible. This was true both with respect to the type of software used and with respect to the information that each company required on its claim form.
One attempt to deal with these problems was the creation, by a consortium of insurance companies, of the National Electronic Information Corporation (NEIC). NEIC's basic function is that of a clearinghouse. It acts as a common interface between the insurance companies and the service providers. It also establishes rigid standards that must be met in order to transmit an electronic claim form to an insurance company. In practice, the service provider sends an electronic claim to a vendor, who performs a service such as screening of the form. The vendor then transmits the form to NEIC, which then re-transmits it to the patient's insurance company. Since it is a computer file, the information in the electronic claim form can then be entered directly into the company's mainframe claims processing system, without the manual re-entry of data, and then processed.
Thus, a coherent system was created that allows for the electronic filing, transmission, and processing of insurance claims. This system is employed by thousands of providers and hundreds of insurance companies.
NEIC was designed to act as a clearinghouse for claims that are 100% text and that conform to very restrictive formats. For claims that meet these conditions it functions well, resulting in substantial savings on administrative costs for the insurance companies. It has been estimated that going to this third stage system results in savings of as much as 60% in claims processing costs.
However, there are many claims that do not meet these conditions. These would include claims that require additional text information that does not fit into the prescribed format and/or claims that require non-text information. In general, these are called “claims with attachments.” “Attachments” are any additional information that must be sent with the “standard text claim form.” This could include: pictures, graphs, additional text not allowed on the standard claim form, sound recordings, etc.
An example of such a claim would be the PAC (Prior Approval Claim), which may be alternately denoted as a “Pretreatment Claim.” These are claims that are sent to the insurance carrier before a procedure is performed. For example, pretreatment claims are often required by dental insurance companies on any procedure over a specified amount, e.g., $200. The aspect of this type of claim which renders it incompatible with the present electronic claim processing system is that the insurance companies require that additional medical evidence be included, i.e., attached to, the text part of the claim form. In an exemplary case, the additional medical evidence is an x-ray.
The goal of the insurance company is to review the claim, i.e., both the text form and attachment, and to do so in a cost-effective manner. The natural next stage in the development of claims processing systems is to attempt to computerized this process.
Scanners are now available that can digitize a dental x-ray, i.e., convert it into a computer file that can be viewed on a monitor. Nevertheless, transforming the medical evidence into digital form is not enough to facilitate electronic processing of claims with attachments. One must also take into consideration the existing claims processing infrastructure, i.e., the legacy infrastructure.
The difficulty with trying to include a digitized x-ray for processing with an electronic claim form, within the current infrastructure, is multifaceted. First, NEIC does not at the present time allow this type of information to be transmitted through NEIC to the insurance companies. Second, with the current system, the claims adjusters
Peeso Thomas R.
Powell, Jr. Raymond H. J.
Westerlund Robert A.
Westerlund & Powell P.C.
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