Benefit Plan Intermediary for Healthcare Payment Assurance
Find Innovative SolutionsGenerate Solutions
Solution Overview
Problem
The complexity of healthcare insurance payment mechanisms, involving multiple sources and cost-sharing plans, leads to increased transaction costs, administrative burdens, and uncertainty for consumers and service providers due to the need to navigate various benefit plans, spending accounts, and out-of-pocket payments.
Innovation Solution
A computer-implemented method and apparatus that determine whether a healthcare transaction will be covered by a benefit plan or a consumer's spending account, allowing for real-time authorization and payment processing, thereby reducing administrative costs and uncertainty by ranking payment sources and ensuring timely payment.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If multiple payment sources and cost-sharing plans are used to cover healthcare costs, then consumers can reduce out-of-pocket expenses, but the complexity of navigating various benefit plans and spending accounts increases transaction costs and administrative burdens
Solution Approach 1:
The patent introduces a benefit plan intermediary as a mediator between consumers, service providers, and multiple payment sources. This intermediary automatically determines payment coverage by evaluating benefit plans, spending accounts, and cost-sharing arrangements, thereby reducing the complexity of navigating multiple payment mechanisms while ensuring comprehensive payment coverage.
Solution Approach 2:
The system enables automatic determination of payment coverage without requiring manual intervention from consumers or providers. The intermediary self-processes the evaluation of multiple payment sources, automatically identifying which plans and accounts apply to each transaction, thus simplifying the payment mechanism while maintaining reliable coverage.
2Speed
If real-time payment determination is implemented, then transaction processing speed increases, but the system complexity and computational requirements increase
Solution Approach 1:
The system performs preliminary evaluation of benefit plans and spending accounts before the actual payment transaction occurs. By pre-determining coverage eligibility and amounts in advance, the system enables rapid real-time processing without requiring complex computational operations during the actual payment, thus increasing speed while managing system complexity.
Solution Approach 2:
The payment determination process is segmented into distinct evaluation stages: identifying applicable benefit plans, calculating coverage amounts, determining cost-sharing obligations, and verifying payment eligibility. This segmentation allows each component to process independently and efficiently, increasing overall processing speed while keeping individual system modules relatively simple.
3Measurement precision
If automatic payment determination is performed for all transactions, then payment accuracy and consumer protection improve, but administrative costs and resource consumption increase
Solution Approach 1:
The system applies automatic payment determination selectively based on transaction characteristics and risk assessments rather than uniformly to all transactions. High-value or complex transactions trigger comprehensive automatic evaluation, while simpler transactions may use streamlined processes, thereby maintaining high payment accuracy for critical cases while reducing overall resource consumption.
Solution Approach 2:
The intermediary incorporates feedback mechanisms that learn from previous transaction outcomes and adjust the level of automatic determination applied to similar future transactions. This feedback loop optimizes the balance between payment accuracy and resource consumption by adapting the evaluation depth based on historical performance and transaction patterns.
Data Source
AI summary
A method may receive data comprising a request to assure payment for a transaction with a consumer, the transaction being associated with a provision of a service or a sale of a product. Thereafter, it may be determined whether payment of at least a portion of the transaction will be covered by a benefit plan associated with the consumer, and additionally, whether the consumer is able to pay for at least a portion of the transaction not covered by the benefit plan. Data is then transmitted authorizing the transaction if a predetermined amount of the transaction will be covered by at least one of the benefit plan or the consumer. Related apparatuses, computer program products, and computer systems are also described.