Automatic Insurance Verification via API Mediator
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Solution Overview
Problem
Current medical service providers face significant challenges in determining patient insurance eligibility and verifying medical benefits due to manual, iterative processes that are time-consuming and prone to human error, compounded by the complexity of unstructured data and varying data formats across different participants in the medical insurance reimbursement process.
Innovation Solution
The implementation of systems and methods that utilize Application Programming Interfaces (APIs) to automatically determine patient insurance eligibility and verify medical benefits information by integrating with other APIs within a medical insurance payment network, creating patient account data structures, and querying memory devices with structured data fields.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If manual iterative processes are used to verify medical benefits information, then flexibility in handling unstructured data formats is maintained, but time consumption increases significantly and human error likelihood increases
Solution Approach 1:
The patent replaces manual mechanical verification processes with an automated computer-based system that uses APIs to electronically exchange and validate medical benefits information between the service provider's computing device and the payor's system, eliminating human intervention in the verification loop
Solution Approach 2:
The patent introduces an intermediary computing system that facilitates automated communication between the medical service provider and the insurance payor through standardized API interfaces, enabling seamless information exchange and verification without direct human-to-human interaction
2Productivity
If manual processes are used to handle varying data formats from different participants, then adaptability to different data structures is maintained, but productivity decreases due to time-consuming manual formatting
Solution Approach 1:
The patent implements a universal API-based communication framework that can handle multiple data formats and structures from different participants (providers, clearinghouses, payors) through a single standardized interface, making the system multi-functional and format-agnostic
Solution Approach 2:
The patent automatically transforms and standardizes varying data formats by changing their structural parameters into a统一的 format that the verification system can process, enabling seamless integration without manual formatting efforts
3Productivity
If automated verification systems are implemented, then processing speed and accuracy improve, but device complexity increases due to integration requirements
Solution Approach 1:
The patent divides the automated verification system into separate modular components: the service provider's computing device, the intermediary verification system, and the payor's system, each performing specific functions that can be independently developed and maintained
Solution Approach 2:
The patent uses an intermediary computing system as a mediator that handles the complex integration logic and API communications, shielding the service provider from integration complexity while enabling automated verification
Data Source
AI summary
The present disclosure generally relates to systems and methods for automatically verifying the medical benefits information of a patient. The present systems and methods automatically verify a patient's medical insurance information by creating a patient account data structure with predetermined data fields. The data fields are then populated with information from a memory device that contains data structures with medical benefits information arranged by an insurance provider identifier.