Real-Time Healthcare Claim Adjudication Payment System
Find Innovative SolutionsGenerate Solutions
Solution Overview
Problem
Healthcare providers often circumvent the claim adjudication process in 100% copay situations, leading to patients being charged more than contracted rates, claims not being counted toward deductibles, and other related issues, due to the lack of detection and minimal penalties, especially in High Deductible Health Plans (HDHPs) and Consumer Driven Health Plans (CDHPs).
Innovation Solution
Implementing a real-time healthcare claims processor-initiated payment system that verifies claim submission and adjudication through e-receipt notifications, ensuring patients are charged the correct, adjudicated amount and preventing providers from unilaterally reversing claims without patient consent, thereby transferring control of claim submission and reversal decisions from providers to patients and claims processors.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of operation
If healthcare providers are allowed to charge patients in 100% copay situations without real-time claim adjudication verification, then providers have flexibility in billing, but patients may be overcharged and claims may not be counted toward deductibles
Solution Approach 1:
The system implements real-time feedback by automatically verifying claim adjudication status and sending notifications to both patients and providers. The claims processor receives feedback from the adjudication system and immediately communicates the verified status to prevent circumvention while maintaining operational efficiency.
Solution Approach 2:
The system enables self-service verification where the claims processor automatically checks adjudication status and initiates notifications without requiring manual intervention from providers or patients. The process is automated to ensure billing accuracy while maintaining provider flexibility.
2Reliability
If real-time payment verification and e-receipt notifications are implemented, then claim circumvention is prevented and billing accuracy is improved, but system complexity and processing time increase
Solution Approach 1:
The claims processor performs multiple functions within a single integrated system: receiving claims, verifying adjudication status, initiating payments, sending notifications, and tracking deductibles. This multi-functionality reduces overall system complexity by consolidating operations rather than requiring separate systems for each function.
Solution Approach 2:
The system performs preliminary verification of claim adjudication status before processing payments. By checking the adjudication status in advance and sending notification immediately, the system prevents circumvention attempts before they can occur, reducing the need for complex post-event detection and correction systems.
3Adaptability or versatility
If healthcare providers can reverse claims without patient consent, then providers can adjust billing, but patients lose control over their claim decisions and may be charged incorrectly
Solution Approach 1:
The system implements real-time feedback by sending immediate notifications to patients when claims are reversed or adjudicated. This ensures patients remain informed of their claim status and have awareness of any changes to their billing, preventing information loss while maintaining provider flexibility in claim management.
Data Source
AI summary
Computerized method requiring claim adjudication to receive patient payment for a product or service provided by a healthcare provider to a patient with full financial responsibility, including receiving a patient claim; re-pricing the claim, automatically initiating a real-time payment authorization request through a payment gateway; receiving a real-time notification that the patient's funding source has verified funds availability, with the funds to be deposited in a designated account for subsequent provider payment; sending the healthcare provider the copay and plan pay pricing edits; and concurrently, sending the patient a payment e-receipt electronically, indicating the total amount due and the amount debited from the patient's funding source, the plan payment, with any difference the copay to be paid directly to the provider. Automatic real-time patient audit enabling payment e-receipts indicate claim adjudications and claim reversals as well as adjudicated copay and plan pay amounts, with the plan payment eliminating adjudication circumvention.