Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Insurance
Reexamination Certificate
2000-07-22
2004-11-30
Thomas, Joseph (Department: 3626)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Insurance
C705S003000
Reexamination Certificate
active
06826536
ABSTRACT:
FIELD OF THE INVENTION
The present invention relates to the field of information systems for the use in reimbursement of medical provider billing, such as anesthesia billing, in regards to the detection, analysis and prevention of overbilling or fraud. It also allows for the development of profiles and utilizes a database relating to specific providers of medical care, such as anesthesiologists.
BACKGROUND OF THE INVENTION
Healthcare costs in the United States continue to rise because of a growing aging population, better education, new drugs and technology and greater healthcare benefits from the government as well as the insurance industry. Healthcare costs are over one trillion dollars a year with fraud and abuse representing about 10% to 15% of this. Conservative estimates put the cost of fraud to the country at over 100 billion dollars a year. The industry, as well as the government, recognizes this problem and have allocated manpower through the FBI and Department of Justice to crack down using the False Claims Act to prosecute these violators. But the discovery of the fraud is still a weak component both with the government as well as on the insurance industry's side.
At present, the federal government relies on personal informants, such as whistle blowers, for discovery, while the insurance industry relies on special investigation units, which are understaffed, lack the proper medical and accounting background and do not have the proper resources to discover where the false claims lie. In addition, the claims process is performed by employees called coders. They have no medical background, let alone have any exposure to medically arcane information such as anesthesia nomenclature. No one in the process of evaluating a claim submitted knows, for example, how to read an anesthesia chart. But the anesthesia chart is a blueprint for whatever billing is submitted by the anesthesiologist.
The head of fraud at insurance companies usually has a background in police work and because of limited medical knowledge, can neither decipher nor interpret technical medical practice information such as an anesthesia chart. Only the medical director of anesthesia, for example, can properly interpret and analyze an anesthesiologist's claim for payment but such proper and qualified anesthesiologist claim interpretations and analysis occurs currently in only 0.01% of anesthesiologist payment claims submitted.
Because of diminished reimbursements throughout the medical community, some doctor providers submit exaggerated billing claims so as to keep their revenue from declining. The software of the present invention is probative of fraud and is not merely an indicator of fraud. The software of the present invention uses a database comprising a history of over a million anesthesia claims to determine whether a particular claim being screened may be aberrant and therefore potentially fraudulent. Thereafter, the doctor in question who submitted the screened claim in question is profiled statistically to see how many standard deviations he or she is deviant generally in submitting claims as compared to his or her peers in regard to his or her pattern of claim billing. No other software process for detecting medical fraud has a built in database nor is any other software capable of addressing specific areas of specialty medical practice, which has triggers which are functionally data processing filters that operate as fraud flags built in to designate and recognize fraudulent bills submitted by medical providers, such as anesthesiologists.
Fraud detection and investigation with the utilization of the unique software of the present invention enables one to identify rapidly and accurately the abuse patterns specific to areas of medical specialty practice provider billing, such as anesthesia billing practices.
Once the software has identified abuse, the present invention commences a drill down process. Anomalous claims that are fraud-suspect are investigated and patterns of fraudulent billing from individual medical care providers are substantiated. This drill-down process, for anesthesisology, for example, utilizes more than sixty years of combined experience of anesthesiologists who detect what appears to the non-anesthesiologist to be subtle abuses but which nonetheless constitute patterns and practices of fraud and abuse in medical billing.
After identifying fraud-suspect aberrations of submitted claims, a proven state of the art recover process takes place using professional staff. This unique recovery process includes a medical provider, such as an anesthesiologist, addressing specific billing issues with the anesthesia provider who submitted fraud-suspect bills. Therefore, the present invention eliminates the arcane nomenclature, confusion and the involvement of three or four layers of non-knowledgeable insurance personnel who lack the requisite skill to analyze even rudimentary medical records, let alone such sophisticated and thus obfuscated and arcane material as anesthesia records.
Among related patents which describe attempts to monitor medical provider billing while preventing fraudulent billing include U.S. Pat. No. 5,995,937 of DeBusk.
DeBusk '937 describes a method of structuring software for creating a health care information management system. In contrast to DeBusk '937, in the present invention the use of software and expert consultants is used to screen health care billing claims to flag possible fraud for further investigation.
However, DeBusk '937 uses the notions of NODE, MODULE, CONTAINER, RESOURCE AND DATA to describe its software system. In FIG. 2 it uses a “clinical pathway” example which shows how an anesthesiologist fits in. DeBusk's examples of fraud relate more to inventory control of supplies in hospitals than the data processing comparison of hospital records with physician payment claim records to flag inconsistencies where there should not be any, which is one of the linchpins of the present invention. The last paragraph of DeBusk '937 claim 6 which states “analyzing the utilization study module . . . ” relates to detecting trends in health care data.
U.S. Pat. No. 6,070,141 of Houvener basically deals with assessing the quality of an identification transaction in an effort to limit identity-based fraud during on-line transactions, which is vastly different from the present invention. It does create a database of “quality score assignments” that are distinguished from the data processing fraud flag filters that are the triggers of the present invention. Houvener '141 uses quality indicators to determine the level of scrutiny. It adjusts historical data as a function of transaction data, which is also used in many commercial applications and is closely related to surveys and polls.
U.S. Pat. No. 5,991,758 of Ellard involves a system and method for indexing information about entities from different information sources. In this way, an entity may be related to records in one or more databases. While the abstract objective of Ellard '758 bears some relation to comparing hospital billing records to those of a physician, the methods used are different from those of the present invention. Ellard '758 uses the notion of a master entity index, MEI. Ellard '758 uses the addition of confidence levels for matching attributes to compare to a threshold level for selecting data records for display, which may be construed as data processing filter triggers.
Moreover, U.S. Pat. No. 6,058,380 of Anderson describes a system for processing financial invoices for billing errors. Anderson '380 describes in Table 3 therein the use of “reasonability” criteria and historical data to determine if billing errors have occurred.
Additionally, the
New York Post
, Jul. 16, 2000 edition, reports as its leading article on page 1 an article entitled “Rent-A-Doc: MD's lease their names to front for medical mills” about medical providers using a multiplicity of entities with different addresses to boost billing.
Currently, these major p
Bleck Carolyn
Thomas Joseph
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