WO2002019235A1 - Electronic, real-time, insurance verification, filing and funding system - Google Patents

Electronic, real-time, insurance verification, filing and funding system Download PDF

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Publication number
WO2002019235A1
WO2002019235A1 PCT/US2001/041679 US0141679W WO0219235A1 WO 2002019235 A1 WO2002019235 A1 WO 2002019235A1 US 0141679 W US0141679 W US 0141679W WO 0219235 A1 WO0219235 A1 WO 0219235A1
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WO
WIPO (PCT)
Prior art keywords
client
insurance
service provider
office
server
Prior art date
Application number
PCT/US2001/041679
Other languages
French (fr)
Inventor
Scott J. Osband
Original Assignee
Pro Quo Investments
Priority date (The priority date 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 date listed.)
Filing date
Publication date
Application filed by Pro Quo Investments filed Critical Pro Quo Investments
Priority to AU2001287170A priority Critical patent/AU2001287170A1/en
Publication of WO2002019235A1 publication Critical patent/WO2002019235A1/en

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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

Definitions

  • the present invention relates to the field of computerized financial transactions. It finds particular application in conjunction with reimbursements made for dentist's and physician's services under insurance plans.
  • a medical service provider (a physician or a dentist) provides service to a patient who has insurance
  • the numerous insurance companies which provide medical and dental insurance to the consuming public have a wide range of different forms which must be submitted to receive compensation. Some of the forms are to be submitted by the doctors and others are to be submitted by the patients. Under some insurance policies, the patient is a co-insurer who is responsible for a portion of the medical bills. In other instances, fees exceed the compensation paid by the insurance company, leaving a balance to be paid by the patient. Some insurance companies pay benefits directly to the patient and the patient has to reimburse the doctor; whereas, other insurers pay the doctor directly.
  • the present invention is a secure web site, accessible from the Internet, which is set up to accept procedure code and insurance carrier input from a service provider's office.
  • the server associated with this web site is programmed to automatically, instantly upon input from the service provider's office, verify a client's benefits, calculate the client benefit, and calculate a service fee.
  • the client is asked to provide insurance, address and billing information.
  • the service provider evaluates the client, determines what service the client needs, and provides the appropriate service or services.
  • the service provider's office then logs on to the secure web site and inputs the insurance carrier and the applicable procedure code or codes for the client.
  • the server immediately connects to the insurance carrier's electronic database and immediately verifies benefits.
  • the server immediately calculates the insurance benefit payable, and provides notice to the service provider's office that an insurance claim for the client is approved and how much the insurance benefit will be.
  • the service provider has the option to accept this calculation or cancel this transaction. This give the service provider an option of obtaining estimates for his and the client's information prior to beginning to provide the service.
  • the server immediately credits the bank account of the service provider with an amount equal to the insurance benefit minus a service fee.
  • the server prints a record of benefits payable and submits an electronic claim to the insurance carrier.
  • the insurance carrier pays the insurance benefit to the operator of the web site.
  • insurance carrier and applicable procedure code data for a particular client could be accomplished by prior input of data to a special software program and uploaded at a later time.
  • the server is also programmed to print out periodic (preferably daily) transaction summary reports at the service provider's office for the service provider's information.
  • the server includes a means for transferring benefits calculated from the insurance carrier's database less a service fee directly to a bank account of the appropriate service provider.
  • a data link is provided between the server and computers of one or more of the insurance companies for electronically conveying claims from the server directly into the insurance companies' computers.
  • a primary advantage of the present invention is that it expedites the processing of medical claims and bills. Another advantage of the present invention is that it reduces the cost of claims processing and speeds the collection of fees by physicians.
  • Another advantage of the present invention is that it reduces the cost of claims processing by service providers and insurance companies.
  • Yet another advantage of the present invention is that it standardizes the insurance claims and medical payment procedure for patients and reduces medical costs through reduced overhead.
  • FIG. 1 is a flowchart showing operation of this invention
  • FIG. 2 is a diagram showing interrelation of all components that are integrated to create this invention
  • FIGs 1 and 2 together illustrate a financial transaction method 10 for a service provider's office 14.
  • service providers which provide services covered by insurance are usually physicians and dentists.
  • this invention is applicable to any provider of services for which insurance benefits are payable.
  • the office 14 has, as is typical for offices nowadays, a computer 18 or a computer network with at least one printer 22 connected to it, and a connection to the Internet 26.
  • the Internet connection 26 can be provided by modem, DSL, T1 line or equivalent service.
  • a third party 30 provides a secure web site 34, accessible from the Internet, which is set up to accept procedure codes and insurance carriers input from the office 14.
  • the server 38 associated with this web site 34 is capable of connecting to an insurance carrier's electronic database 42.
  • the server 38 is programmed to automatically, instantly, upon input, verify a client's benefits, calculate the client benefit, and calculate a service fee.
  • the third party 30 must obtain agreement, preferably prior agreement, from the service provider or the client that insurance benefits will be paid directly to the third party 30.
  • Such agreements are generally called assignments.
  • the client When a client first visits the service provider's office 14, the client is asked to provide insurance, address and billing information. Upon subsequent visits, (i.e. if said client is returning) the client is asked to verify insurance, address and billing information and, if any of this information has changed, to revise this information.
  • the service provider evaluates the client and determines what service the client needs. Standard procedure codes are available in the industry, so the office 14 is able to assign an applicable procedure code to the service the client needs. The office 14 then logs on to the secure web site 34 and inputs the insurance carrier and the applicable procedure code for the client.
  • the server 38 immediately connects to the insurance carrier's electronic database 42 and verifies benefits for the client. Connection may be made through the Internet or some other form of electronic or wireless means of communication. If the client is not found, not covered or has used up his or her benefits for the fiscal year, the server 38 provides immediate notice to the service provider's office 14 via said web site 34 that an insurance claim for the client is denied. If the client is found, is covered, and has not used up his or her benefits for the fiscal year, the server 38 immediately calculates the insurance benefit payable and a service fee. Then, the server 38 provides notice to the service provider's office 14 via the web site 34 that an insurance claim for the client is approved and how much the insurance benefit and the service fee will be. The service provider's office 14 is then presented with the option to accept this calculation or cancel the transaction. This give the service provider an option of obtaining estimates for his and the client's information prior to beginning to provide the service.
  • the server 38 immediately credits the bank account 46 of the service provider with an amount equal to the insurance benefit minus the service fee.
  • the server 38 prints a record 50 of benefits payable at the office 14 for client and provider verification and client approval signature, and submits an electronic claim to the insurance carrier.
  • the server is programmed so that each electronic claim is automatically made in a form that is acceptable to the particular insurance carrier to which it is submitted so that it is never rejected.
  • the server 38 clears the current transaction and is ready to process another transaction for the same or a new client.
  • the insurance carrier pays the insurance benefit to the third party 30.
  • This payment may be made electronically, by wire transfer, by check or equivalent method.
  • the end result is that insurance benefits are immediately paid to service providers; clients are correctly and immediately billed; clients can immediately pay their portion of the bill (if any); and insurance claims are immediately and correctly filed. Immediate payment more than compensates the service providers for the small service fee that is charged.
  • the whole system 10 dramatically reduces the amount of paper that must be processed and time spans, thus reducing the service provider's and insurance companies overheads. Thus this system 10 reduces costs to the consumer.
  • input of insurance carrier and applicable procedure code data for a particular client could be accomplished by prior input of data to a software program already resident on the service provider's computer 18. The data could then be uploaded at a later time.
  • the server 38 is also programmed to print out daily transaction summary reports 54 at the service provider's office for the service provider's information. While daily transaction summary reports 54 are preferred, it is possible to obtain summary reports54 at will or on a different frequency.

Abstract

A secure web site (34) is set up to accept procedure codes and insurance carrier input from a service provider's office (14). The service provider's office (14) logs on to the secure web site (34) and inputs the insurance carrier and applicable procedure code(s) for a client. The web site server (38) connects to the insurance carrier's electronic database (42), verifies benefits, calculates the insurance benefit payable and provides notice to the service provider's office (14) that an insurance claim for the client is approved. The server (38) may then credit the bank account of the service provider with an amount equal to the insurance benefit minus a service fee, print benefits payable record and submit an electronic claim to the insurance carrier. The insurance carrier pays the insurance benefit to the web site operator. Periodic transaction summaries are also available from the web site server (38).

Description

ELECTRONIC. REAL-TIME. INSURANCE VERIFICATION. FILING AND FUNDING SYSTEM
Technical Field
The present invention relates to the field of computerized financial transactions. It finds particular application in conjunction with reimbursements made for dentist's and physician's services under insurance plans.
Background Art
When a medical service provider (a physician or a dentist) provides service to a patient who has insurance, it is necessary for the service provider to process a wide variety of papers and forms to receive compensation for their services. The numerous insurance companies which provide medical and dental insurance to the consuming public have a wide range of different forms which must be submitted to receive compensation. Some of the forms are to be submitted by the doctors and others are to be submitted by the patients. Under some insurance policies, the patient is a co-insurer who is responsible for a portion of the medical bills. In other instances, fees exceed the compensation paid by the insurance company, leaving a balance to be paid by the patient. Some insurance companies pay benefits directly to the patient and the patient has to reimburse the doctor; whereas, other insurers pay the doctor directly. Even as to monies paid by the patient, some patients pay by check or cash at the time the services are rendered, some pay by credit card, and others are invoiced. The processing of the numerous different types of insurance forms and modes of payment has created a major paper processing problem. Many physicians, dentists and clinics have to hire extra staff whose sole job function is to handle this paperwork. The extra staff increases overhead which is passed on to the consumer in the form of higher medical bills.
Then once the forms are filled out and submitted, the physician still faces the problem of collecting the amounts invoiced to the insurance companies and patients. Forms which are filled out improperly are commonly returned to the physician to be processed again. The insurance companies commonly take extended time for processing before reimbursement checks are mailed even when forms are properly filled out. In some instances, the processing time is several months. If the claim exceeds the limits of the insureds' policies, the same processing time elapses before the physician is advised that he is receiving only partial payment. When only partial payments are received from the insurance companies the physician must invoice the patients again, possibly months after the services are provided. These delays between the time the services are provided and when compensation is received again increases the physician's and dentist's overhead. This increase in overhead again results in higher medical costs to the consumer.
Development of a new and improved computerized financial transaction system for physicians and other service providers which can overcome the above referenced problems represents a great improvement in the field of insurance claim processing and satisfies a long felt need of the service provider.
Disclosure of Invention
The present invention is a secure web site, accessible from the Internet, which is set up to accept procedure code and insurance carrier input from a service provider's office. The server associated with this web site is programmed to automatically, instantly upon input from the service provider's office, verify a client's benefits, calculate the client benefit, and calculate a service fee. The client is asked to provide insurance, address and billing information. The service provider evaluates the client, determines what service the client needs, and provides the appropriate service or services. The service provider's office then logs on to the secure web site and inputs the insurance carrier and the applicable procedure code or codes for the client. The server immediately connects to the insurance carrier's electronic database and immediately verifies benefits. If the client is covered, the server immediately calculates the insurance benefit payable, and provides notice to the service provider's office that an insurance claim for the client is approved and how much the insurance benefit will be. The service provider has the option to accept this calculation or cancel this transaction. This give the service provider an option of obtaining estimates for his and the client's information prior to beginning to provide the service. If the service provider accepts the transaction, the server immediately credits the bank account of the service provider with an amount equal to the insurance benefit minus a service fee. At the same time the server prints a record of benefits payable and submits an electronic claim to the insurance carrier. At a later time, the insurance carrier pays the insurance benefit to the operator of the web site.
Instead of inputting data directly to the web site, insurance carrier and applicable procedure code data for a particular client could be accomplished by prior input of data to a special software program and uploaded at a later time. The server is also programmed to print out periodic (preferably daily) transaction summary reports at the service provider's office for the service provider's information.
In accordance with one aspect of the present invention, the server includes a means for transferring benefits calculated from the insurance carrier's database less a service fee directly to a bank account of the appropriate service provider.
In accordance with yet another aspect of the present invention, a data link is provided between the server and computers of one or more of the insurance companies for electronically conveying claims from the server directly into the insurance companies' computers.
A primary advantage of the present invention is that it expedites the processing of medical claims and bills. Another advantage of the present invention is that it reduces the cost of claims processing and speeds the collection of fees by physicians.
Another advantage of the present invention is that it reduces the cost of claims processing by service providers and insurance companies.
Yet another advantage of the present invention is that it standardizes the insurance claims and medical payment procedure for patients and reduces medical costs through reduced overhead.
Further advantages of the present invention are that it simplifies the service provider's accounting and minimizes the service provider's accounts receivable.
An appreciation of the other aims and objectives of the present invention and an understanding of it may be achieved by referring to the accompanying drawings and description of a preferred embodiment.
Brief Description of Drawings
Figure 1 is a flowchart showing operation of this invention
Figure 2 is a diagram showing interrelation of all components that are integrated to create this invention
Best Mode for Carrying Out Invention
Figures 1 and 2 together illustrate a financial transaction method 10 for a service provider's office 14. Nowadays, service providers which provide services covered by insurance are usually physicians and dentists. However, this invention is applicable to any provider of services for which insurance benefits are payable. The office 14 has, as is typical for offices nowadays, a computer 18 or a computer network with at least one printer 22 connected to it, and a connection to the Internet 26. The Internet connection 26 can be provided by modem, DSL, T1 line or equivalent service.
A third party 30 provides a secure web site 34, accessible from the Internet, which is set up to accept procedure codes and insurance carriers input from the office 14. The server 38, associated with this web site 34 is capable of connecting to an insurance carrier's electronic database 42. The server 38 is programmed to automatically, instantly, upon input, verify a client's benefits, calculate the client benefit, and calculate a service fee. Naturally, the third party 30 must obtain agreement, preferably prior agreement, from the service provider or the client that insurance benefits will be paid directly to the third party 30. Such agreements are generally called assignments.
When a client first visits the service provider's office 14, the client is asked to provide insurance, address and billing information. Upon subsequent visits, (i.e. if said client is returning) the client is asked to verify insurance, address and billing information and, if any of this information has changed, to revise this information.
The service provider evaluates the client and determines what service the client needs. Standard procedure codes are available in the industry, so the office 14 is able to assign an applicable procedure code to the service the client needs. The office 14 then logs on to the secure web site 34 and inputs the insurance carrier and the applicable procedure code for the client.
The server 38 immediately connects to the insurance carrier's electronic database 42 and verifies benefits for the client. Connection may be made through the Internet or some other form of electronic or wireless means of communication. If the client is not found, not covered or has used up his or her benefits for the fiscal year, the server 38 provides immediate notice to the service provider's office 14 via said web site 34 that an insurance claim for the client is denied. If the client is found, is covered, and has not used up his or her benefits for the fiscal year, the server 38 immediately calculates the insurance benefit payable and a service fee. Then, the server 38 provides notice to the service provider's office 14 via the web site 34 that an insurance claim for the client is approved and how much the insurance benefit and the service fee will be. The service provider's office 14 is then presented with the option to accept this calculation or cancel the transaction. This give the service provider an option of obtaining estimates for his and the client's information prior to beginning to provide the service.
If the service provider's office 14 accepts the transaction, the server 38 immediately credits the bank account 46 of the service provider with an amount equal to the insurance benefit minus the service fee. At the same time the server 38 prints a record 50 of benefits payable at the office 14 for client and provider verification and client approval signature, and submits an electronic claim to the insurance carrier. The server is programmed so that each electronic claim is automatically made in a form that is acceptable to the particular insurance carrier to which it is submitted so that it is never rejected.
If the service provider's office 14 does not accept the transaction, the server 38 clears the current transaction and is ready to process another transaction for the same or a new client.
At a later time, the insurance carrier pays the insurance benefit to the third party 30. This payment may be made electronically, by wire transfer, by check or equivalent method.
The end result is that insurance benefits are immediately paid to service providers; clients are correctly and immediately billed; clients can immediately pay their portion of the bill (if any); and insurance claims are immediately and correctly filed. Immediate payment more than compensates the service providers for the small service fee that is charged. The whole system 10 dramatically reduces the amount of paper that must be processed and time spans, thus reducing the service provider's and insurance companies overheads. Thus this system 10 reduces costs to the consumer. Of course, instead of inputting data directly to the web site 34, input of insurance carrier and applicable procedure code data for a particular client could be accomplished by prior input of data to a software program already resident on the service provider's computer 18. The data could then be uploaded at a later time. The server 38 is also programmed to print out daily transaction summary reports 54 at the service provider's office for the service provider's information. While daily transaction summary reports 54 are preferred, it is possible to obtain summary reports54 at will or on a different frequency.
The following reference numerals are used on Figures 1 and 2:
10 Financial transaction method
14 Service provider's office
18 Service providers's computer(s) 22 Service providers' printer(s)
26 Internet connection
30 Third party financial transaction company
34 Web site
38 Server 42 Insurance company electronic database
46 Bank
50 Transaction record
54 . Periodic transaction summary report
The financial transaction system 10 has been described with reference to a particular embodiment. Other modifications and enhancements can be made without departing from the spirit and scope of the claims that follow.

Claims

Claims
1. A financial transaction method for a service provider's office, said office having a computer, a printer, a connection to the Internet, a bank account and being visited by a client in need of services, said service provider providing service for which insurance benefits are payable, said method comprising the steps of: a. providing a secure web site, operated by a third party, accessible from the Internet, for accepting a procedure code and an applicable insurance carrier for said client from said office; b. providing a server, associated with said web site, also operated by said third party, capable of connecting to an insurance carrier's electronic database, verifying said client's benefit, calculating said client benefit and calculating a service fee; said server being programmed for automatic operation; c. said third party obtaining assignment of insurance benefits to said third party; d. if said client is new, upon said client's first visit to said service provider's office, having said client provide insurance, address and billing information; e. if said client is returning, having said client verify insurance, address and billing information and, if any of said information has changed, having said client revise said information; f. determining from said information provided by said client, said applicable insurance carrier; g. said service provider evaluating said client and determining said applicable procedure code; h. said office logging on to said secure web site; i. said office inputting said applicable insurance carrier and said applicable procedure code for said client; j. said server immediately connecting to said applicable insurance carrier's electronic database; k. said server immediately verifying benefits for said client; I. if said client is not found, not covered or has used up his or her benefits for the fiscal year, said server providing immediate notice to said service provider's office via said web site that an insurance claim for said client is denied; m. if said client is found, is covered, and has not used up his or her benefits for the fiscal year, said server immediately calculating said insurance benefit payable and said service fee; n. said server immediately providing notice to said service provider's office via said web site that an insurance claim for said client is approved and how much said insurance benefit and said service fee will be; o. said service provider indicating acceptance of said calculation; p. upon indication of acceptance,: i. said server immediately crediting said bank account with an amount equal to said insurance benefit minus said service fee; ii. said server immediately printing a record of benefits payable at said office for client and service provider verification, and client signature; iii. said server immediately submitting an electronic claim to said insurance carrier; and iv. said insurance carrier paying said insurance benefit to said third party; q. upon indication of non-acceptance, said server clearing said transaction; and r. said server periodically printing a summary of benefits payable to said service provider at said office for service provider information. A financial transaction method as described in claim 1 in which the step of inputting said applicable insurance carrier and said applicable procedure code for said client is accomplished by prior input of data to a software program.
PCT/US2001/041679 2000-08-30 2001-08-08 Electronic, real-time, insurance verification, filing and funding system WO2002019235A1 (en)

Priority Applications (1)

Application Number Priority Date Filing Date Title
AU2001287170A AU2001287170A1 (en) 2000-08-30 2001-08-08 Electronic, real-time, insurance verification, filing and funding system

Applications Claiming Priority (2)

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US65235900A 2000-08-30 2000-08-30
US09/652,359 2000-08-30

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Cited By (4)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2002079934A2 (en) * 2001-04-02 2002-10-10 Ge Financial Assurance Holdings, Inc. Insurance information management system and method
US20120016763A1 (en) * 2010-07-16 2012-01-19 Bradley Kirschner Method of providing prescription safety eyewear
US10311521B1 (en) 2014-05-12 2019-06-04 Liberty Mutual Insurance Company Item inventory and item replacement
US10339581B2 (en) 2010-07-16 2019-07-02 Eyelation, Inc. Dual-camera apparatus for deriving dimensional measurements and method of personalizing lens selection

Citations (4)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US4491725A (en) * 1982-09-29 1985-01-01 Pritchard Lawrence E Medical insurance verification and processing system
US5325293A (en) * 1992-02-18 1994-06-28 Dorne Howard L System and method for correlating medical procedures and medical billing codes
US6012035A (en) * 1993-07-08 2000-01-04 Integral Business Services, Inc. System and method for supporting delivery of health care
US6208973B1 (en) * 1998-02-27 2001-03-27 Onehealthbank.Com Point of service third party financial management vehicle for the healthcare industry

Patent Citations (4)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US4491725A (en) * 1982-09-29 1985-01-01 Pritchard Lawrence E Medical insurance verification and processing system
US5325293A (en) * 1992-02-18 1994-06-28 Dorne Howard L System and method for correlating medical procedures and medical billing codes
US6012035A (en) * 1993-07-08 2000-01-04 Integral Business Services, Inc. System and method for supporting delivery of health care
US6208973B1 (en) * 1998-02-27 2001-03-27 Onehealthbank.Com Point of service third party financial management vehicle for the healthcare industry

Cited By (6)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2002079934A2 (en) * 2001-04-02 2002-10-10 Ge Financial Assurance Holdings, Inc. Insurance information management system and method
WO2002079934A3 (en) * 2001-04-02 2002-12-19 Ge Financial Assurance Holding Insurance information management system and method
US20120016763A1 (en) * 2010-07-16 2012-01-19 Bradley Kirschner Method of providing prescription safety eyewear
US10339581B2 (en) 2010-07-16 2019-07-02 Eyelation, Inc. Dual-camera apparatus for deriving dimensional measurements and method of personalizing lens selection
US10311521B1 (en) 2014-05-12 2019-06-04 Liberty Mutual Insurance Company Item inventory and item replacement
US11449945B1 (en) 2014-05-12 2022-09-20 Liberty Mutual Insurance Company Item inventory and item replacement

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